Provider Demographics
NPI:1972562601
Name:FULLER, BRIAN GEORGE (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:GEORGE
Last Name:FULLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PORTERS GLEN PL
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-9164
Mailing Address - Country:US
Mailing Address - Phone:919-452-8264
Mailing Address - Fax:
Practice Address - Street 1:15 PORTERS GLEN PL
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-9164
Practice Address - Country:US
Practice Address - Phone:919-452-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist