Provider Demographics
NPI:1780157040
Name:FULLER, MARCUS MITCHELL (LAC , LMT, MACOM)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:MITCHELL
Last Name:FULLER
Suffix:
Gender:M
Credentials:LAC , LMT, MACOM
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 3205
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686-3205
Mailing Address - Country:US
Mailing Address - Phone:907-255-8413
Mailing Address - Fax:
Practice Address - Street 1:300 N WILLSON AVE STE 2003
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3597
Practice Address - Country:US
Practice Address - Phone:406-577-2168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK138929171100000X
MTMED-ACU-LIC-70143171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist