| Provider / Organization | NPI | Date Certified |
|---|---|---|
| TIARA LEI FUNKHOUSER | 1306578786 | 2022-06-25 |
Tiara Lei Funkhouser is registered with the National Plan and Provider Enumeration System and has been issued an National Provider Identifier (NPI) of 1306578786. Registration indicates Tiara Lei Funkhouser is a provider of access to adult/geriatric primary care providers services with a specialization in Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant Access to Pediatric Primary Care Providers (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (Physician Assistant, ) (Physician Assistants & Advanced Practice Nursing Providers, Physician Assistant) (All Other Specialties & Provider Types, ) (Physician Assistant, Physician Assistants & Advanced Practice Nursing Providers)
| Entity Type | Individual |
| Provider Name | Tiara Lei Funkhouser PA |
| Practice Office Address | 463380 STATE ROAD 200 UNIT B YULEE, FL US |
| Practice Office Telephone | 9045009808 |
| Practice Office Fax | 9044320401 |
| Mailing Address | 705 WELLS RD STE 300 ORANGE PARK, FL 320732982 US |
| Business Telephone | 9042826331 |
| Business Fax | 9046191080 |
| Code | Practice | License No State |
|---|---|---|
| 363A00000X PRIMARY | Access to Adult/Geriatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician AssistantAccess to Pediatric Primary Care Providers Physician Assistants & Advanced Practice Nursing Providers Physician Assistant Physician Assistant Physician Assistants & Advanced Practice Nursing Providers Physician Assistant All Other Specialties & Provider Types Physician Assistant Physician Assistants & Advanced Practice Nursing Providers |