Provider Demographics
NPI:1063419679
Name:FULK, JOHN D (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FULK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:SUITE 4800
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-454-5900
Mailing Address - Fax:309-454-2820
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:SUITE 4800
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-454-5900
Practice Address - Fax:309-454-2820
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2019-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL085001126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL581690Medicare ID - Type Unspecified
ILS96160Medicare UPIN