Healthcare Provider Details

I. General information

NPI: 1487170627
Provider Name (Legal Business Name): BYRON GARTH FULK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 HEALTH CAMPUS DR
ROCKINGHAM VA
22801-8679
US

IV. Provider business mailing address

PO BOX 1430
HARRISONBURG VA
22803-1430
US

V. Phone/Fax

Practice location:
  • Phone: 540-689-1110
  • Fax: 540-689-1119
Mailing address:
  • Phone: 540-564-7084
  • Fax: 540-564-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110005948
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: