Healthcare Provider Details

I. General information

NPI: 1023334158
Provider Name (Legal Business Name): MR. BILLY L FUSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2010
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6656 ANTIGUA BLVD
SAN DIEGO CA
92124
US

IV. Provider business mailing address

6656 ANTIGUA BLVD
SAN DIEGO CA
92124
US

V. Phone/Fax

Practice location:
  • Phone: 678-644-1007
  • Fax:
Mailing address:
  • Phone: 678-644-1007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: