Healthcare Provider Details

I. General information

NPI: 1902967243
Provider Name (Legal Business Name): COY FULLEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

427 N 12TH ST
PLUMMER ID
83851
US

IV. Provider business mailing address

PO BOX 388
PLUMMER ID
83851-0388
US

V. Phone/Fax

Practice location:
  • Phone: 208-686-1931
  • Fax: 208-686-5133
Mailing address:
  • Phone: 208-686-1931
  • Fax: 208-686-5133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBF4836978
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-0589
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: