=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750586509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL W FULLER ATC. LAT.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3414 GOLDEN RD
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-8336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-939-7500
-----------------------------------------------------
Fax | 903-597-1245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 REDBUD CIR
-----------------------------------------------------
City | WHITEHOUSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75791-4405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-871-2634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | AT1427
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------