Healthcare Provider Details

I. General information

NPI: 1073669495
Provider Name (Legal Business Name): GARY M FULLER RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 HEARST AVE
SAN FRANCISCO CA
94112-1348
US

IV. Provider business mailing address

351 HEARST AVE
SAN FRANCISCO CA
94112-1348
US

V. Phone/Fax

Practice location:
  • Phone: 415-272-2203
  • Fax:
Mailing address:
  • Phone: 415-272-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number327890
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: