Healthcare Provider Details

I. General information

NPI: 1306578786
Provider Name (Legal Business Name): TIARA LEI FUNKHOUSER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2022
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463380 STATE ROAD 200 UNIT B
YULEE FL
32097-3240
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-500-9808
  • Fax: 904-432-0401
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-619-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: