Basic Information
| Provider Information | |||||||||
| NPI: | 1720652167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TULLOUS | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | ELDON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177257900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178775858 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2021 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1023704 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.