Provider Demographics
NPI:1396785390
Name:FUNK, BRANDON SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:SCOTT
Last Name:FUNK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 W I 35 FRONTAGE RD STE 250
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8561
Mailing Address - Country:US
Mailing Address - Phone:405-757-3340
Mailing Address - Fax:405-757-3520
Practice Address - Street 1:2017 W I 35 FRONTAGE RD STE 250
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8561
Practice Address - Country:US
Practice Address - Phone:405-757-3340
Practice Address - Fax:405-757-3520
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17988363A00000X
OK1465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200201770AMedicaid
OK200201770AMedicaid
OKOK401014Medicare PIN