Provider Demographics
NPI:1093718843
Name:FUNK, KATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 HOLTON AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3208
Mailing Address - Country:US
Mailing Address - Phone:509-453-1606
Mailing Address - Fax:509-453-5321
Practice Address - Street 1:306 HOLTON AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3208
Practice Address - Country:US
Practice Address - Phone:509-453-1606
Practice Address - Fax:509-453-5321
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60025OtherGROUP HEALTH WA PROVIDER
91-149-2005OtherFEDERAL TAX ID
WA105 8270Medicaid
WA601-265-836OtherWASHINGTON STATE UBI
WA60025OtherGROUP HEALTH WA PROVIDER
WA105 8270Medicaid