MEDICARE: GARY M FULLER RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SM0705X	Medical-Surgical Clinical Nurse Specialist	327890	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	327890	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1073669495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY M FULLER RNFA

Provider Business Mailing Address
First Line	:	351 HEARST AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94112-1348
Country	:	US
Telephone Number	:	415-272-2203
Fax Number	:

Provider Business Practice Location Address
First Line	:	351 HEARST AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94112-1348
Country	:	US
Telephone Number	:	415-272-2203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2007
Last Update Date	:	02/08/2017

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