Healthcare Provider Details

I. General information

NPI: 1669002721
Provider Name (Legal Business Name): NICOLE MARIE FUNK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2020
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD STE 304
BOISE ID
83706-1341
US

IV. Provider business mailing address

901 N CURTIS RD STE 304
BOISE ID
83706-1341
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-4263
  • Fax: 208-375-0597
Mailing address:
  • Phone: 208-342-4263
  • Fax: 208-375-0597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1843
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-1843
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1843
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: