Basic Information
| Provider Information | |||||||||
| NPI: | 1629088364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLAGAR | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 MED TECH PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232328301 | ||||||||
| FaxNumber: | 4232328304 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 MED TECH PKWY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232328301 | ||||||||
| FaxNumber: | 4232328304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 41401 | TN | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.