Healthcare Provider Details

I. General information

NPI: 1063617587
Provider Name (Legal Business Name): ANDREA MARIE FULLERTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 S CLIFTON STE 400
WICHITA KS
67208
US

IV. Provider business mailing address

PO BOX 8035
WICHITA KS
67208-0035
US

V. Phone/Fax

Practice location:
  • Phone: 316-636-1550
  • Fax: 316-689-9769
Mailing address:
  • Phone: 316-689-9135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number046772
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: