MEDICARE: RICHARD S BULLARD APRN

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	363L00000X	Nurse Practitioner	APRN11014272	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255903779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD S BULLARD APRN

Provider Business Mailing Address
First Line	:	45 PITTWICK LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7003
Country	:	US
Telephone Number	:	386-517-4103
Fax Number	:	352-273-5683

Provider Business Practice Location Address
First Line	:	45 PITTWICK LN
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-7003
Country	:	US
Telephone Number	:	386-517-4103
Fax Number	:	386-241-1022

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

Provider Enumeration Date	:	07/14/2021
Last Update Date	:	04/09/2022

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