MEDICARE: TROY MICHAEL FULTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	RN168108	AZ
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	248871	AZ
3	2084P0800X	Psychiatry Physician	248871	AZ

General Provider Information

NPI Number	:	1053937599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TROY MICHAEL FULTON

Provider Business Mailing Address
First Line	:	560 W BROWN RD STE 1011
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-3222
Country	:	US
Telephone Number	:	480-509-7738
Fax Number	:

Provider Business Practice Location Address
First Line	:	560 W BROWN RD STE 1011
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85201-3222
Country	:	US
Telephone Number	:	480-509-7738
Fax Number	:	480-856-9069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2020
Last Update Date	:	07/23/2024

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Directions to “ TROY MICHAEL FULTON ” Practice Location

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