Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | ||
N | 225100000X | Physical Therapist | PT3076 | WA |
N | 2251G0304X | Physical Therapist - Geriatrics | ||
N | 2251G0304X | Physical Therapist - Geriatrics | PT3076 | WA |
NPI | 1124028634 |
---|---|
Provider Name | Mr. James C Fuller |
First Address | Federal Way, WA 98063 |
Second Address | Federal Way, WA 98003 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2005 |
Last Update Date | 09/06/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7096167 | (05) | WA |
G8870695 | MEDICARE PTAN (01) | WA |