Healthcare Provider Details

I. General information

NPI: 1609767227
Provider Name (Legal Business Name): JUSTIN SCOTT FULLER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2025
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 NE A ST
MADRAS OR
97741-1844
US

IV. Provider business mailing address

4311 11TH AVE NE STE 200
SEATTLE WA
98105-6367
US

V. Phone/Fax

Practice location:
  • Phone: 541-475-4800
  • Fax: 541-475-4805
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: