Provider Demographics
NPI:1548222334
Name:FUNK, MICHAEL COLIN (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:COLIN
Last Name:FUNK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740209
Mailing Address - Street 2:DEPT 1073
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2006
Practice Address - Country:US
Practice Address - Phone:217-342-2121
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
L98771Medicare UPIN
K07726Medicare ID - Type Unspecified