Provider Demographics
NPI:1417985540
Name:FULLER, DONALD M (MPT)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:M
Last Name:FULLER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 W. 6 ST.
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2503
Mailing Address - Country:US
Mailing Address - Phone:814-456-6000
Mailing Address - Fax:814-456-6060
Practice Address - Street 1:6419 CAROLINA BEACH RD STE C
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-3672
Practice Address - Country:US
Practice Address - Phone:910-332-3828
Practice Address - Fax:910-251-0421
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
PAPT014020L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018935630025Medicaid
001939987OtherBC/BS