Provider Demographics
NPI:1710225743
Name:FULLER, SCOTT W (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:W
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 1:2550 GREENTREE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-5739
Mailing Address - Country:US
Mailing Address - Phone:503-805-2600
Mailing Address - Fax:
Practice Address - Street 1:9923 SW ARCTIC DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4194
Practice Address - Country:US
Practice Address - Phone:503-646-8482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor