Provider Demographics
NPI:1891491858
Name:FULLMER, RYAN WATKIN I (CHS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WATKIN
Last Name:FULLMER
Suffix:I
Gender:M
Credentials:CHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 FAIRWAY LN
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-4139
Mailing Address - Country:US
Mailing Address - Phone:970-641-0905
Mailing Address - Fax:303-666-2112
Practice Address - Street 1:996 FAIRWAY LN
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-4139
Practice Address - Country:US
Practice Address - Phone:970-641-0905
Practice Address - Fax:303-666-2112
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1663156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist