MEDICARE: JOHN D FULK P.A.

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	363A00000X	Physician Assistant	085001126	IL

General Provider Information

NPI Number	:	1063419679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN D FULK P.A.

Provider Business Mailing Address
First Line	:	1302 FRANKLIN AVE
Second Line	:	SUITE 4800
City	:	NORMAL
State	:	IL
Zip	:	61761-3551
Country	:	US
Telephone Number	:	309-454-5900
Fax Number	:	309-454-2820

Provider Business Practice Location Address
First Line	:	1302 FRANKLIN AVE
Second Line	:	SUITE 4800
City	:	NORMAL
State	:	IL
Zip	:	61761-3551
Country	:	US
Telephone Number	:	309-454-5900
Fax Number	:	309-454-2820

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

Provider Enumeration Date	:	06/29/2005
Last Update Date	:	04/04/2019

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Directions to “ JOHN D FULK P.A.” Practice Location

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