Provider Demographics
NPI:1407180763
Name:FULTON, LYDIA SUZANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:SUZANNE
Last Name:FULTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 HIGHMOOR CT
Mailing Address - Street 2:
Mailing Address - City:OAK POINT
Mailing Address - State:TX
Mailing Address - Zip Code:75068-6136
Mailing Address - Country:US
Mailing Address - Phone:618-335-0992
Mailing Address - Fax:
Practice Address - Street 1:508 HIGHMOOR CT
Practice Address - Street 2:
Practice Address - City:OAK POINT
Practice Address - State:TX
Practice Address - Zip Code:75068-6136
Practice Address - Country:US
Practice Address - Phone:618-335-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-18
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22766363A00000X
TXPA09733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003502OtherST LICENSE