Provider Demographics
NPI:1306677083
Name:FULTZ, ANDREW (PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:FULTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 E COMMERCE CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-3200
Mailing Address - Country:US
Mailing Address - Phone:865-475-3101
Mailing Address - Fax:865-475-9213
Practice Address - Street 1:102 E COMMERCE CT
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-3200
Practice Address - Country:US
Practice Address - Phone:865-475-3101
Practice Address - Fax:865-475-9213
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15862225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist