Basic Information
| Provider Information | |||||||||
| NPI: | 1811593080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | AS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 BABCOCK RD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106147953 | ||||||||
| FaxNumber: | 2106144190 | ||||||||
| Practice Location | |||||||||
| Address1: | 2140 BABCOCK RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106147953 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2020 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2159173 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.