Basic Information
| Provider Information | |||||||||
| NPI: | 1417985540 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1337 W. 6 ST. | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165052503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144566000 | ||||||||
| FaxNumber: | 8144566060 | ||||||||
| Practice Location | |||||||||
| Address1: | 6419 CAROLINA BEACH RD STE C | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284123672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323828 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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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 | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT014020L | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0018935630025 | 05 | PA | MEDICAID | 001939987 | 01 | BC/BS | OTHER |