Healthcare Provider Details

I. General information

NPI: 1255599163
Provider Name (Legal Business Name): MICHAEL JOHN FULLAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N OCEAN AVE
PATCHOGUE NY
11772-2012
US

IV. Provider business mailing address

25 NORTHUMBERLAND DR
SHOREHAM NY
11786-2000
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-5004
  • Fax:
Mailing address:
  • Phone: 631-846-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number006268
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: