Healthcare Provider Details

I. General information

NPI: 1790236255
Provider Name (Legal Business Name): NATHAN FULLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 PACE ST
LONGMONT CO
80504-3052
US

IV. Provider business mailing address

1611 PACE ST
LONGMONT CO
80504-3052
US

V. Phone/Fax

Practice location:
  • Phone: 303-776-7590
  • Fax:
Mailing address:
  • Phone: 303-776-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0021543
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: