Basic Information
| Provider Information | |||||||||
| NPI: | 1801989090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | JOSEPH | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3104 BLUE LAKE DRIVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059771949 | ||||||||
| FaxNumber: | 2059771933 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059771949 | ||||||||
| FaxNumber: | 7062262283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN110452 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000550756A | 05 | GA | MEDICAID |