Healthcare Provider Details

I. General information

NPI: 1538582077
Provider Name (Legal Business Name): ROSS ASHMORE FULLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 BAXTER ST
ATHENS GA
30606-3712
US

IV. Provider business mailing address

55 WHITE STREET EXT
WATKINSVILLE GA
30677-6010
US

V. Phone/Fax

Practice location:
  • Phone: 912-429-6196
  • Fax:
Mailing address:
  • Phone: 912-429-6196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN210210
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: