Provider Demographics
NPI:1538582077
Name:FULLER, ROSS ASHMORE (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:ASHMORE
Last Name:FULLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 OAKCREST DR
Mailing Address - Street 2:APARTMENT 526
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1749
Mailing Address - Country:US
Mailing Address - Phone:912-429-6196
Mailing Address - Fax:
Practice Address - Street 1:1310 OAKCREST DR
Practice Address - Street 2:APARTMENT 526
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1749
Practice Address - Country:US
Practice Address - Phone:912-429-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210210367500000X
SC214946163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered