Healthcare Provider Details

I. General information

NPI: 1891999876
Provider Name (Legal Business Name): JAMES A FULLERTON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N ADAMS ST
QUINCY FL
32351-2404
US

IV. Provider business mailing address

108 N ADAMS ST
QUINCY FL
32351-2404
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-2080
  • Fax: 229-890-3397
Mailing address:
  • Phone: 850-875-0333
  • Fax: 850-875-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA010487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: