Provider Demographics
NPI:1326151499
Name:FUNK, WENDELL LAVERN (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:LAVERN
Last Name:FUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HARRISBURG AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2959
Mailing Address - Country:US
Mailing Address - Phone:717-299-9551
Mailing Address - Fax:717-399-9266
Practice Address - Street 1:230 HARRISBURG AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2959
Practice Address - Country:US
Practice Address - Phone:717-299-9551
Practice Address - Fax:717-399-9266
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019811-E2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0812284Medicaid
PA0812284Medicaid
PAFU63044Medicare ID - Type Unspecified