Provider Demographics
NPI:1326391160
Name:FULLERTON, CHASE BRANDON
Entity Type:Individual
Prefix:MR
First Name:CHASE
Middle Name:BRANDON
Last Name:FULLERTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2889 SOLLIE RD
Mailing Address - Street 2:APT 1410
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-5532
Mailing Address - Country:US
Mailing Address - Phone:407-702-3674
Mailing Address - Fax:
Practice Address - Street 1:2889 SOLLIE RD
Practice Address - Street 2:APT 1410
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-5532
Practice Address - Country:US
Practice Address - Phone:407-702-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant