Provider Demographics
NPI:1902276355
Name:MCNULTY, GARRETT ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:ALLEN
Last Name:MCNULTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11051 N SHERMAN RD
Mailing Address - Street 2:
Mailing Address - City:EDGERTON
Mailing Address - State:WI
Mailing Address - Zip Code:53534-9002
Mailing Address - Country:US
Mailing Address - Phone:608-884-3354
Mailing Address - Fax:608-884-5022
Practice Address - Street 1:11051 N SHERMAN RD
Practice Address - Street 2:
Practice Address - City:EDGERTON
Practice Address - State:WI
Practice Address - Zip Code:53534-9002
Practice Address - Country:US
Practice Address - Phone:608-884-3354
Practice Address - Fax:608-884-5022
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64648-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902276355Medicaid
WI1902276355OtherBCBSWI
WI1902276355Medicaid
WIK400264294-000054176Medicare PIN