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General NPI Number Information
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NPI Number | 1184233173
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Entity Type | Organization
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Legal Business Name | BRYAN D FULLER MD PA
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Dates
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Enumeration Date | 07/27/2020
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Last Update Date | 07/08/2022
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Provider Practice Location Address
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Address Line | 625 UNITED DR STE 330
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City | CONWAY
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State | AR
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Zip | 72032-7828
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Country | US
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Telephone | 501-748-8450
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Fax | 501-379-8428
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Provider Business Mailing Address
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Address Line | 625 UNITED DR STE 330
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City | CONWAY
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State | AR
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Zip | 72032-7828
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Country | US
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Telephone | 501-748-8450
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Fax | 501-379-8428
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JENNIFER SMITH
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Credential |
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Telephone | 501-748-8450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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