Individual
MR. TIMOTHY V. FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
555 LINN ST, ALLEGAN, MI 49010-1524
(269) 686-4143
Mailing address
1331 34TH ST, ALLEGAN, MI 49010-9384
(269) 686-4143
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
4704138811
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10-4315429
—
MI
01
—
43OZ36149
BLUE CROSS
—
Enumeration date
03/20/2007
Last updated
11/30/2012
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