Provider Demographics
NPI:1346877834
Name:FULTON, DALLAS DAVARR (CRNA)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:DAVARR
Last Name:FULTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 KATY FWY STE 206
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-1476
Mailing Address - Country:US
Mailing Address - Phone:713-400-2990
Mailing Address - Fax:713-400-2993
Practice Address - Street 1:11800 ASTORIA BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6041
Practice Address - Country:US
Practice Address - Phone:713-400-2990
Practice Address - Fax:713-400-2993
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011008339163W00000X
TXAP145711367500000X
KS13-114322-121163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse