1932734803 NPI number — DR. SHANE AMOUR FULTON CNA , MD

Table of content: DR. SHANE AMOUR FULTON CNA , MD (NPI 1932734803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932734803 NPI number — DR. SHANE AMOUR FULTON CNA , MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTON
Provider First Name:
SHANE
Provider Middle Name:
AMOUR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
CNA , MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932734803
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6131 N 16TH ST APT D204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-1711
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-986-6877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6131 N 16TH ST APT D204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-986-6877
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 374U00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376K00000X , with the licence number: CNA1000056885 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NONE . This is a "NONE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com