Provider Demographics
NPI:1265101935
Name:FULLAM, NATHAN THOMAS (DPT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:FULLAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 TRISTRAM CIR
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:NJ
Mailing Address - Zip Code:08051-2245
Mailing Address - Country:US
Mailing Address - Phone:484-947-8823
Mailing Address - Fax:
Practice Address - Street 1:115 N ROUTE 73 UNIT 80
Practice Address - Street 2:
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-9202
Practice Address - Country:US
Practice Address - Phone:856-335-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02040500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist