Provider Demographics
NPI:1275102147
Name:FUNK, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FUNK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 3RD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-7808
Mailing Address - Country:US
Mailing Address - Phone:402-649-1629
Mailing Address - Fax:
Practice Address - Street 1:52550 848TH RD
Practice Address - Street 2:
Practice Address - City:NELIGH
Practice Address - State:NE
Practice Address - Zip Code:68756-2026
Practice Address - Country:US
Practice Address - Phone:402-649-1629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE80622163W00000X
NE101708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse