Provider Demographics
NPI:1649467200
Name:FULTON, TRAVIS JAMES (PTA)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:FULTON
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 1:104 BRAVE EAGLE TRL
Mailing Address - Street 2:PO BOX 1611
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-9567
Mailing Address - Country:US
Mailing Address - Phone:940-641-1183
Mailing Address - Fax:
Practice Address - Street 1:117 RUNNING BEAR TRAIL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234
Practice Address - Country:US
Practice Address - Phone:940-641-1183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2051270225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant