Provider Demographics
NPI:1558632232
Name:FULLMER, JOSHUA (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 1/2 KEENER ST
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-4723
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 NORTH AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-3122
Practice Address - Country:US
Practice Address - Phone:970-248-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer