Provider Demographics
NPI:1033863451
Name:FUNG, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:FUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:CHRISTENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2913 5TH AVE NE STE 101
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6748
Mailing Address - Country:US
Mailing Address - Phone:855-255-1750
Mailing Address - Fax:
Practice Address - Street 1:2913 5TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6748
Practice Address - Country:US
Practice Address - Phone:855-255-1750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA61218361363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant