Individual
BRYAN DALE FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
625 UNITED DR STE 220, CONWAY, AR 72032-7835
(501) 499-8300
(501) 379-8428
Mailing address
625 UNITED DR STE 330, CONWAY, AR 72032-7828
(501) 499-8300
(501) 379-8428
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
E4442
AR
207V00000X
Obstetrics & Gynecology Physician
Primary
E4442
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5N365
BLUE/CROSS PROVIDER NO.
AR
Enumeration date
06/07/2006
Last updated
07/08/2022
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