1669618468 NPI number — MR. ANDRE LAVAL FULLER PTA

Table of content: MR. ANDRE LAVAL FULLER PTA (NPI 1669618468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669618468 NPI number — MR. ANDRE LAVAL FULLER PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
ANDRE
Provider Middle Name:
LAVAL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669618468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4560 SE INTERNATIONAL WAY
Provider Second Line Business Mailing Address:
STE. 100 CONSONUS HEALTHCARE SERVICES
Provider Business Mailing Address City Name:
MILWAUKIE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-206-5200
Provider Business Mailing Address Fax Number:
971-206-5203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 LEBO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-206-5200
Provider Business Practice Location Address Fax Number:
971-206-5203
Provider Enumeration Date:
12/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225200000X , with the licence number:  P160039642 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com