Provider Demographics
NPI:1972626869
Name:FUNK, PEGGY A (MSPT)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:A
Last Name:FUNK
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 196TH ST SE APT E302
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8506
Mailing Address - Country:US
Mailing Address - Phone:206-595-6250
Mailing Address - Fax:
Practice Address - Street 1:1819 S LAKE STEVENS RD
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-2060
Practice Address - Country:US
Practice Address - Phone:425-334-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009121225100000X
IN05008790A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8806689Medicare ID - Type Unspecified