Basic Information
| Provider Information | |||||||||
| NPI: | 1154382463 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1590 ROSECRANS AVE | ||||||||
| Address2: | STE D357 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902663727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108833388 | ||||||||
| FaxNumber: | 9514617074 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 S SPALDING DR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902121800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103857755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | G83197 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | G83197 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.