Provider Demographics
NPI:1942357306
Name:FULTON, PAMELA ANGEL (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ANGEL
Last Name:FULTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 QUINCY ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5021
Mailing Address - Country:US
Mailing Address - Phone:505-453-4727
Mailing Address - Fax:877-860-2279
Practice Address - Street 1:1308 QUINCY ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5021
Practice Address - Country:US
Practice Address - Phone:505-453-4727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP 00616363LF0000X
NMCNP00616363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93708220Medicaid
NM429693YZPW-342566Medicare PIN
NMP72785Medicare UPIN
NM93708220Medicaid
NM346729905Medicare PIN