Provider Demographics
NPI:1902335979
Name:FULLER, BRENT (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17740 LAYTON PATH
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5214
Mailing Address - Country:US
Mailing Address - Phone:651-955-1424
Mailing Address - Fax:
Practice Address - Street 1:7231 SUNWOOD DR NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-5190
Practice Address - Country:US
Practice Address - Phone:763-236-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist