Provider Demographics
NPI:1265815575
Name:FULLER, AARON BRYCE (COTA)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:BRYCE
Last Name:FULLER
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4432 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-7409
Mailing Address - Country:US
Mailing Address - Phone:480-272-6215
Mailing Address - Fax:
Practice Address - Street 1:8008 S JESSE OWENS PKWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6516
Practice Address - Country:US
Practice Address - Phone:602-243-2780
Practice Address - Fax:602-243-7079
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5360224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant