Provider Demographics
NPI:1669134664
Name:FULTZ, AUSTIN (CRNA DNAP)
Entity type:Individual
Prefix:MR
First Name:AUSTIN
Middle Name:
Last Name:FULTZ
Suffix:
Gender:M
Credentials:CRNA DNAP
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 2697
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-7697
Mailing Address - Country:US
Mailing Address - Phone:270-745-1111
Mailing Address - Fax:270-745-1026
Practice Address - Street 1:250 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1760
Practice Address - Country:US
Practice Address - Phone:270-745-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017299367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered