Provider Demographics
NPI:1821522038
Name:FULKS, BROGAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BROGAN
Middle Name:
Last Name:FULKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:BROGAN
Other - Middle Name:WALTERS
Other - Last Name:FULKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1928 ALCOA HWY
Mailing Address - Street 2:POB-B #127
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1502
Mailing Address - Country:US
Mailing Address - Phone:865-305-8787
Mailing Address - Fax:865-305-8261
Practice Address - Street 1:1928 ALCOA HWY
Practice Address - Street 2:POB-B #127
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1502
Practice Address - Country:US
Practice Address - Phone:865-305-8787
Practice Address - Fax:865-305-8261
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN626001636OtherPARENT ORGANIZATION TIN