Basic Information
| Provider Information | |||||||||
| NPI: | 1205354073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULGENCIO | ||||||||
| FirstName: | PATRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6105 ORANGEGATE DR | ||||||||
| Address2: | |||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928865217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146093060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11500 BROOKSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | DOWNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902414917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629045000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2017 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A17169 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.