Provider Demographics
NPI:1639270945
Name:FULLER, MARK A (DC, LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MN
Mailing Address - Zip Code:56455-0193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 CURTIS AVE
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MN
Practice Address - Zip Code:56455-0193
Practice Address - Country:US
Practice Address - Phone:218-546-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2948111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU34004Medicare UPIN