Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 036084191 | IL |
N | 111NI0900X | Internist | 036084191 | IL |
N | 2084N0400X | Neurologist | 036084191 | IL |
Y | 2084N0400X | Neurologist | G140674 | CA |
NPI | 1043304611 |
---|---|
Provider Name | Tonya F. Fuller |
First Address | Sacramento, CA 95865-5228 |
Second Address | Modesto, CA 95355-4201 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2006 |
Last Update Date | 09/02/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036084191 | (05) | IL |
036084191 | IL LICENSE (01) | IL |
F91912 | (02) |