Provider Demographics
NPI:1255793964
Name:FULTON, TOM (MED;MA;ATC)
Entity type:Individual
Prefix:MR
First Name:TOM
Middle Name:
Last Name:FULTON
Suffix:
Gender:M
Credentials:MED;MA;ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40700 YUCCA LN
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-8122
Mailing Address - Country:US
Mailing Address - Phone:760-345-2848
Mailing Address - Fax:760-345-8173
Practice Address - Street 1:40700 YUCCA LN
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-8122
Practice Address - Country:US
Practice Address - Phone:760-345-2848
Practice Address - Fax:760-345-8173
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer