Provider Demographics
NPI:1841267135
Name:FULTON, KEITH QUENTIN (CRNA)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:QUENTIN
Last Name:FULTON
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 1:8885 PATCHES CV
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-3801
Mailing Address - Country:US
Mailing Address - Phone:901-619-0310
Mailing Address - Fax:
Practice Address - Street 1:8885 PATCHES CV
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-3801
Practice Address - Country:US
Practice Address - Phone:901-619-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-05
Last Update Date:2008-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9001367500000X
MS81-0068367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3600621Medicaid
TN3155973OtherBLUE CROSS
TN3600621Medicaid