Provider Demographics
NPI:1831229871
Name:FUNKE, ALISA (MD)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:FUNKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1896 FOX HILL RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24503-6497
Mailing Address - Country:US
Mailing Address - Phone:434-907-3174
Mailing Address - Fax:
Practice Address - Street 1:2007 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-1111
Practice Address - Country:US
Practice Address - Phone:434-947-5321
Practice Address - Fax:434-947-5324
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101260110207ND0101X, 207N00000X
IDM11258207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01529781Medicaid
CO01529781Medicaid