Provider Demographics
NPI:1871856641
Name:FUNK, RYAN KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KEVIN
Last Name:FUNK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5309
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:1580 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-779-7978
Practice Address - Fax:651-779-7656
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012018706207R00000X
MN1071132085R0001X
MN568782085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MNP01249784OtherRAILROAD MEDICARE
MNENROLLEDMedicaid