Basic Information
| Provider Information | |||||||||
| NPI: | 1053536268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUNK | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCGREGOR | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LYNNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3303 SW BOND AVE # 16D | ||||||||
| Address2: | OHSU DEPARTMENT OF DERMATOLOGY | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183376 | ||||||||
| FaxNumber: | 5033468106 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE # 16D | ||||||||
| Address2: | OHSU DEPARTMENT OF DERMATOLOGY | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034183376 | ||||||||
| FaxNumber: | 5033468106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2007 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 47554 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | 47554 | CO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207N00000X | 173370 | OR | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 82253862 | 05 | CO | MEDICAID |