Provider Demographics
NPI:1871121947
Name:FULLENKAMP, AUSTIN JOSEPH PERRY
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JOSEPH PERRY
Last Name:FULLENKAMP
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5701
Mailing Address - Country:US
Mailing Address - Phone:949-874-1825
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS ST STE 210
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-5701
Practice Address - Country:US
Practice Address - Phone:949-874-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program