Provider Demographics
NPI:1750586509
Name:FULLER, DANIEL W (ATC LAT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:FULLER
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:447 REDBUD CIR
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-4405
Mailing Address - Country:US
Mailing Address - Phone:903-871-2634
Mailing Address - Fax:
Practice Address - Street 1:3414 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8336
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-597-1245
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT1427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist