Provider Demographics
NPI:1447262183
Name:FULLAN, NEIL P (MD)
Entity type:Individual
Prefix:
First Name:NEIL
Middle Name:P
Last Name:FULLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2475 UNIVERSITY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-5099
Mailing Address - Country:US
Mailing Address - Phone:920-469-1201
Mailing Address - Fax:920-469-3404
Practice Address - Street 1:2475 UNIVERSITY AVE STE A
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-5099
Practice Address - Country:US
Practice Address - Phone:920-469-1201
Practice Address - Fax:920-469-3404
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI282302084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIE38428Medicare UPIN
WI07528Medicare ID - Type Unspecified