Provider Demographics
NPI:1851802276
Name:FUNK, SAM XAVIER
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:XAVIER
Last Name:FUNK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 W CENTRAL PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804-1741
Mailing Address - Country:US
Mailing Address - Phone:660-342-6871
Mailing Address - Fax:
Practice Address - Street 1:1536 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804-1741
Practice Address - Country:US
Practice Address - Phone:660-342-6871
Practice Address - Fax:660-342-6871
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program