Provider Demographics
NPI:1427831585
Name:FULK, EMILY ELLEN (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ELLEN
Last Name:FULK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 CORNERSTONE XING APT 12
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-4540
Mailing Address - Country:US
Mailing Address - Phone:309-530-5060
Mailing Address - Fax:
Practice Address - Street 1:3400 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3430
Practice Address - Country:US
Practice Address - Phone:262-551-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7435-23363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical