Provider Demographics
NPI:1114167830
Name:FUNK, GAYLE LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:GAYLE
Middle Name:LYNN
Last Name:FUNK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1221 MADISON ST
Practice Address - Street 2:STE 1020
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1380
Practice Address - Country:US
Practice Address - Phone:206-215-2658
Practice Address - Fax:206-991-2363
Is Sole Proprietor?:No
Enumeration Date:2009-02-21
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60255470363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1114167830Medicaid