Provider Demographics
NPI:1417582727
Name:KING, FUNSHO
Entity Type:Individual
Prefix:
First Name:FUNSHO
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6053 HUDSON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1000
Mailing Address - Country:US
Mailing Address - Phone:651-410-7955
Mailing Address - Fax:
Practice Address - Street 1:6053 HUDSON RD STE 200
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1000
Practice Address - Country:US
Practice Address - Phone:651-410-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7201363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health