Healthcare Provider Details

I. General information

NPI: 1770957094
Provider Name (Legal Business Name): DANIEL EVERETT FULLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S MAIN ST
WALNUT CREEK CA
94596-5318
US

IV. Provider business mailing address

3908 RENNER ST
CARMICHAEL CA
95608-2629
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4000
  • Fax:
Mailing address:
  • Phone: 916-944-0336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000418
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: