Provider Demographics
NPI:1912165713
Name:FULLER, KISTI POPE (MD)
Entity Type:Individual
Prefix:
First Name:KISTI
Middle Name:POPE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KISTI
Other - Middle Name:DAWN
Other - Last Name:POPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4343 N SCOTTSDALE RD STE 150
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3351
Mailing Address - Country:US
Mailing Address - Phone:480-866-8787
Mailing Address - Fax:480-863-9770
Practice Address - Street 1:1840 S STAPLEY DR STE 131
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6683
Practice Address - Country:US
Practice Address - Phone:480-866-8787
Practice Address - Fax:480-863-9770
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV24641207VM0101X
AZ48767207VM0101X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1912165713Medicaid
NV24641OtherSTATE LICENSE