Individual
GARY TRENT FULLMER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
P.A.-C
Contact information
Practice address
485 S DOBSON RD STE 110, CHANDLER, AZ 85224-5600
(480) 728-4470
(480) 728-4499
Mailing address
PO BOX 33269, PHOENIX, AZ 85067-3269
(602) 406-4786
(916) 636-4358
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
2774
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2774
PHYSICIAN ASSISTANT LICEN
AZ
Enumeration date
05/11/2006
Last updated
12/05/2024
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