Gary Fulkerson, P.A.

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

7347 Issued in AZ

Practice address

3001 N Main St Ste 1C
Prescott Valley, AZ 86314-1215

Phone

(928) 458-5470

Fax

(928) 458-5979

NPI assigned

Dec 19, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Enrolled in AZ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1134950400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1553644800000",
    "number": "1730165176",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3001 N MAIN ST STE 1C",
            "city": "PRESCOTT VALLEY",
            "state": "AZ",
            "postal_code": "863141215",
            "telephone_number": "928-458-5470",
            "fax_number": "928-458-5979"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3001 N MAIN ST STE 1C",
            "city": "PRESCOTT VALLEY",
            "state": "AZ",
            "postal_code": "863141215",
            "telephone_number": "928-458-5470",
            "fax_number": "928-458-5979"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULKERSON",
        "first_name": "GARY",
        "credential": "P.A.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-12-19",
        "last_updated": "2019-03-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "UT",
            "license": "103161-1206",
            "primary": false
        },
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NV",
            "license": "PA1673",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "AZ",
            "license": "7347",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physician Assistant in Prescott Valley, AZ
• Providers in Prescott Valley, AZ by specialty
• Physician Assistant in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 27, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.