Provider Demographics
NPI:1811593080
Name:FULTON, RYAN E (AS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:E
Last Name:FULTON
Suffix:
Gender:M
Credentials:AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 BABCOCK RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-7953
Mailing Address - Fax:210-614-4190
Practice Address - Street 1:2140 BABCOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4424
Practice Address - Country:US
Practice Address - Phone:210-614-7953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2159173225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant