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General NPI Number Information
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NPI Number | 1851530398
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Entity Type | Individual
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Provider Name | MICHAEL W FULLER MD
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Gender | Male
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Dates
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Enumeration Date | 02/06/2009
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 48 EAST ST
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City | FORT EDWARD
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State | NY
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Zip | 12828-1811
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Country | US
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Telephone | 518-824-8630
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Fax | 518-824-2302
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Provider Business Mailing Address
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Address Line | 9 CAREY RD
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City | QUEENSBURY
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State | NY
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Zip | 12804-7880
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Country | US
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Telephone | 518-761-0300
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Fax | 518-824-2388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 265403
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License Number State | NY
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