Healthcare Provider Details

I. General information

NPI: 1417929084
Provider Name (Legal Business Name): ROBERT SCOTT FULTON A.T.C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W BROOKS ST RM. E-8
NORMAN OK
73019-1018
US

IV. Provider business mailing address

112 PARKCREST CT
NOBLE OK
73068-9365
US

V. Phone/Fax

Practice location:
  • Phone: 405-325-8387
  • Fax:
Mailing address:
  • Phone: 405-872-7538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: