Provider Demographics
NPI:1376882126
Name:FULTS, GAVEN M
Entity Type:Individual
Prefix:MR
First Name:GAVEN
Middle Name:M
Last Name:FULTS
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 1:14708 KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-4514
Mailing Address - Country:US
Mailing Address - Phone:402-309-0523
Mailing Address - Fax:
Practice Address - Street 1:14708 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68116-4514
Practice Address - Country:US
Practice Address - Phone:402-309-0523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist