Healthcare Provider Details

I. General information

NPI: 1760226716
Provider Name (Legal Business Name): THOMAS LANCE FULGHUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 VOYAGER DR
GREEN BAY WI
54311-8303
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-431-1810
  • Fax:
Mailing address:
  • Phone: 920-431-1810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number101347-851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125-084945
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: