Provider Demographics
NPI:1043222748
Name:FULLER, ROSS B (DC)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:B
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-2101
Mailing Address - Country:US
Mailing Address - Phone:307-548-9338
Mailing Address - Fax:307-548-9335
Practice Address - Street 1:223 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-2101
Practice Address - Country:US
Practice Address - Phone:307-548-9338
Practice Address - Fax:307-548-9335
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY615111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313386OtherBLUE CROSS BLUE SHIELD
WY313386OtherBLUE CROSS BLUE SHIELD
WYU71358Medicare UPIN