Provider Demographics
NPI:1780975664
Name:FULLER, JEREMY R (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:FULLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2803
Mailing Address - Country:US
Mailing Address - Phone:509-458-5800
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2803
Practice Address - Country:US
Practice Address - Phone:509-458-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN42071367500000X
WAAP60308924367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered