Provider Demographics
NPI:1134181175
Name:FULKS, BRENTON GLENN (CRNA)
Entity type:Individual
Prefix:
First Name:BRENTON
Middle Name:GLENN
Last Name:FULKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740209
Mailing Address - Street 2:DEPT 40039
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:1817 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1853
Practice Address - Country:US
Practice Address - Phone:407-896-7438
Practice Address - Fax:407-896-7440
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2990102367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
G2142EMedicare ID - Type Unspecified