Provider Demographics
NPI:1124028634
Name:FULLER, JAMES C (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:C
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6225
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98063
Mailing Address - Country:US
Mailing Address - Phone:253-839-3403
Mailing Address - Fax:253-839-3412
Practice Address - Street 1:31200 23RD AVE SOUTH
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003
Practice Address - Country:US
Practice Address - Phone:253-839-3403
Practice Address - Fax:253-839-3412
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT3076225100000X, 2251G0304X
2251G0304X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8870695OtherMEDICARE PTAN
WA7096167Medicaid