Provider Demographics
NPI:1780645994
Name:FUNK, MARY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 MANKATO AVE
Mailing Address - Street 2:WINONA CLINIC
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-457-7667
Mailing Address - Fax:507-457-7704
Practice Address - Street 1:859 MANKATO AVE
Practice Address - Street 2:WINONA CLINIC
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-457-7667
Practice Address - Fax:507-457-7704
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0972002363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103827300Medicaid
MN103827300Medicaid
S28420Medicare UPIN