Provider Demographics
NPI:1346582228
Name:FULTON, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:FULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MARKET CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-3261
Mailing Address - Country:US
Mailing Address - Phone:540-992-1251
Mailing Address - Fax:540-992-5958
Practice Address - Street 1:60 MARKET CENTER WAY
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3261
Practice Address - Country:US
Practice Address - Phone:540-992-1251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204426208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics