Healthcare Provider Details

I. General information

NPI: 1609600600
Provider Name (Legal Business Name): SAMUEL AARON FULLMER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 INTERNATIONAL BLVD
OAKLAND CA
94601-2228
US

IV. Provider business mailing address

2950 INTERNATIONAL BLVD
OAKLAND CA
94601-2228
US

V. Phone/Fax

Practice location:
  • Phone: 510-535-4400
  • Fax:
Mailing address:
  • Phone: 510-535-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number355097
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95034962
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: