MEDICARE: LYDIA SUZANNE FULTON PA-C

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	22766	CA
2	363A00000X	Physician Assistant	PA09733	TX

General Provider Information

NPI Number	:	1407180763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA SUZANNE FULTON PA-C

Provider Business Mailing Address
First Line	:	508 HIGHMOOR CT
Second Line	:
City	:	OAK POINT
State	:	TX
Zip	:	75068-6136
Country	:	US
Telephone Number	:	618-335-0992
Fax Number	:

Provider Business Practice Location Address
First Line	:	508 HIGHMOOR CT
Second Line	:
City	:	OAK POINT
State	:	TX
Zip	:	75068-6136
Country	:	US
Telephone Number	:	618-335-0992
Fax Number	:

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

Provider Enumeration Date	:	09/18/2009
Last Update Date	:	04/17/2015

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