Provider Demographics
NPI:1902364011
Name:FULLER, MARSHAL (MNSC, APRN, AGACNP-B)
Entity Type:Individual
Prefix:
First Name:MARSHAL
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:MNSC, APRN, AGACNP-B
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TODD LN
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-2819
Mailing Address - Country:US
Mailing Address - Phone:501-416-5021
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST # 584
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-7541
Practice Address - Fax:501-320-7068
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006163363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care