Provider Demographics
NPI:1346216512
Name:FUNK, RENEE LINDA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:LINDA
Last Name:FUNK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1900
Mailing Address - Country:US
Mailing Address - Phone:320-255-5657
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:320-255-5656
Practice Address - Fax:320-654-2044
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant