Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | G37354 | CA |
NPI | 1033188560 |
---|---|
Provider Name | Cole Marie Fulwider |
First Address | Los Alamitos, CA 90720-6428 |
Second Address | Los Alamitos, CA 90720-6428 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2006 |
Last Update Date | 18/06/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A47051 | (02) | CA |
G37354A | PTAN (01) | CA |