Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 27-019443 | NY |
NPI | 1013243310 |
---|---|
Provider Name | Mr. Patrick M Fuller |
First Address | Fayetteville, NY 13066-2021 |
Second Address | Fayetteville, NY 13066-2021 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2009 |
Last Update Date | 19/10/2011 |