Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 1298 | DE |
Y | 222Z00000X | Podiatrist | 1298 | DE |
N | 224P00000X | Prosthetist | 1298 | DE |
NPI | 1487089124 |
---|---|
Provider Name | Mr. Bryan Carroll Fuller |
First Address | Charlottesville, VA 22901-1412 |
Second Address | Charlottesville, VA 22901-1412 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2013 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1215362850 | (05) | VA |