MEDICARE: NEIL P FULLAN M.D.

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	2084P0804X	Child & Adolescent Psychiatry Physician	28230	WI

General Provider Information

NPI Number	:	1447262183
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEIL P FULLAN M.D.

Provider Business Mailing Address
First Line	:	2475 UNIVERSITY AVE STE A
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-469-1201
Fax Number	:	920-469-3404

Provider Business Practice Location Address
First Line	:	2475 UNIVERSITY AVE STE A
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54302-5099
Country	:	US
Telephone Number	:	920-469-1201
Fax Number	:	920-469-3404

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	02/08/2026

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