Provider Demographics
NPI:1457440984
Name:FULLER, NORMAN EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:NORMAN
Middle Name:EUGENE
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 W COMMERCIAL DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6937
Mailing Address - Country:US
Mailing Address - Phone:907-376-2475
Mailing Address - Fax:907-373-5154
Practice Address - Street 1:833 W COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-6937
Practice Address - Country:US
Practice Address - Phone:907-376-2475
Practice Address - Fax:907-373-5154
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK251111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0251Medicaid
AK152625Medicare ID - Type UnspecifiedINDIVIDUAL
AK152624Medicare ID - Type UnspecifiedGROUP
AKCH0251Medicaid