Provider Demographics
NPI:1104989268
Name:FULLMER, TIMOTHY MICHAEL (MSPT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:FULLMER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-1361
Mailing Address - Country:US
Mailing Address - Phone:607-687-2495
Mailing Address - Fax:
Practice Address - Street 1:150 BROAD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1361
Practice Address - Country:US
Practice Address - Phone:607-687-2495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022693225100000X
NY022693-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist