Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0214X | Pediatric Pulmonologist | L0800 | TX |
NPI | 1184796401 |
---|---|
Provider Name | Dr. Jason Fullmer |
First Address | Austin, TX 78759-5264 |
Second Address | Austin, TX 78759-5264 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2006 |
Last Update Date | 16/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
154700203 | (05) | TX |
L0800 | (02) | TX |