Individual
CHUCK B FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
660 SHOSHONE ST E, SUITE 130, TWIN FALLS, ID 83301-6110
(208) 732-3400
(208) 732-3300
Mailing address
660 SHOSHONE ST E, SUITE 130, TWIN FALLS, ID 83301-6110
(208) 732-3400
(208) 732-3300
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-499
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010147741
REGENCE BLUE SHIELD IND #
ID
01
—
PAQR4
BLUE CROSS IND #
ID
Enumeration date
10/04/2005
Last updated
01/10/2008
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