Provider Demographics
NPI:1891999876
Name:FULLERTON, JAMES A (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:A
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-2404
Mailing Address - Country:US
Mailing Address - Phone:850-875-0333
Mailing Address - Fax:850-875-0335
Practice Address - Street 1:108 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-2404
Practice Address - Country:US
Practice Address - Phone:229-985-2080
Practice Address - Fax:229-890-3397
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA010487225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant