Provider Demographics
NPI:1235307000
Name:FULLING, GREGORY ALAN (MS PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALAN
Last Name:FULLING
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2142 W RAILROAD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-7813
Mailing Address - Country:US
Mailing Address - Phone:360-426-0175
Mailing Address - Fax:360-432-2193
Practice Address - Street 1:2142 W RAILROAD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-7813
Practice Address - Country:US
Practice Address - Phone:360-426-0175
Practice Address - Fax:360-432-2193
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8347130Medicaid
S74503Medicare PIN
WA8347130Medicaid
WAS74503Medicare UPIN