Provider Demographics
NPI:1487089124
Name:FULLER, BRYAN CARROLL (CPO)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:CARROLL
Last Name:FULLER
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 RIO RD W STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1412
Mailing Address - Country:US
Mailing Address - Phone:434-529-8882
Mailing Address - Fax:434-529-8942
Practice Address - Street 1:612 RIO RD W STE 5
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1412
Practice Address - Country:US
Practice Address - Phone:434-529-8882
Practice Address - Fax:434-529-8882
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1298224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1215362850Medicaid
VA1215362850Medicaid