Provider Demographics
NPI:1891848057
Name:FUNK, DALE EUGENE (PT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:EUGENE
Last Name:FUNK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1615
Mailing Address - Country:US
Mailing Address - Phone:509-865-3141
Mailing Address - Fax:509-865-7388
Practice Address - Street 1:501 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1615
Practice Address - Country:US
Practice Address - Phone:509-865-3141
Practice Address - Fax:509-865-7388
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8208FUOtherBLUE SHIELD PIN #
WA7123979Medicaid
WA8397143Medicaid
WAR12118OtherUPIN
WA12566OtherGROUP HEALTH PIN #
WA2400OtherGROUP HEALTH GROUP #
WA0178563OtherLABOR & IND. GROUP #
WA0178562OtherLABOR & IND. PIN #
WA8801024Medicare PIN
WA8397143Medicaid