Individual
TONYA F. FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
600 COFFEE RD, MODESTO, CA 95355-4201
(209) 550-4785
Mailing address
PO BOX 255228, SACRAMENTO, CA 95865-5228
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
036084191
IL
2084N0400X
Neurology Physician
036084191
IL
2084N0400X
Neurology Physician
Primary
G140674
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036084191
IL LICENSE
IL
05
—
036084191
—
IL
Enumeration date
10/03/2006
Last updated
02/09/2021
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