Healthcare Provider Details

I. General information

NPI: 1780752659
Provider Name (Legal Business Name): FULLERTON GYN ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 04/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BASTANCHURY RD #170
FULLERTON CA
92835-3419
US

IV. Provider business mailing address

301 W BASTANCHURY RD #170
FULLERTON CA
92835-3419
US

V. Phone/Fax

Practice location:
  • Phone: 714-879-6571
  • Fax: 714-446-9140
Mailing address:
  • Phone: 714-879-6571
  • Fax: 714-446-9140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG5122
License Number StateCA

VIII. Authorized Official

Name: DR. NATHAN E SCOTT
Title or Position: OWNER- CEO
Credential: MD
Phone: 714-879-6571