Provider Demographics
NPI:1972160448
Name:FULTZ, DANIEL ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:FULTZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14330 CROGHAN PIKE
Mailing Address - Street 2:
Mailing Address - City:MOUNT UNION
Mailing Address - State:PA
Mailing Address - Zip Code:17066-8838
Mailing Address - Country:US
Mailing Address - Phone:814-542-8630
Mailing Address - Fax:814-542-2828
Practice Address - Street 1:7776 SR 655
Practice Address - Street 2:SUITE D
Practice Address - City:REEDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17084
Practice Address - Country:US
Practice Address - Phone:717-667-7607
Practice Address - Fax:717-667-7497
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI003615225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant