Basic Information
| Provider Information | |||||||||
| NPI: | 1598349227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 VALLEY VIEW AVE E | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551195871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634380528 | ||||||||
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| Practice Location | |||||||||
| Address1: | 45 10TH ST W | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551021062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512323000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2021 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7962 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.