Provider Demographics
NPI:1295612133
Name:FUNKHOUSER, MARK (PRSS;CHW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FUNKHOUSER
Suffix:
Gender:M
Credentials:PRSS;CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 CRADLE MOUNTAIN DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2194
Mailing Address - Country:US
Mailing Address - Phone:812-449-4343
Mailing Address - Fax:
Practice Address - Street 1:2029 CRADLE MOUNTAIN DR UNIT 2
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-2194
Practice Address - Country:US
Practice Address - Phone:812-449-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPRSS-5038175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist