Provider Demographics
NPI:1568404317
Name:FUNSTON, KIMBERLY SUE (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:FUNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:SUE
Other - Last Name:SEDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:405 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1290
Mailing Address - Country:US
Mailing Address - Phone:641-621-2200
Mailing Address - Fax:641-621-2335
Practice Address - Street 1:405 MONROE ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1290
Practice Address - Country:US
Practice Address - Phone:641-621-2200
Practice Address - Fax:641-621-2335
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
47525Medicare PIN