Provider Demographics
NPI:1306614904
Name:FULLER, BENJAMIN A
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:A
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 LUISA ST STE 7
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4177
Mailing Address - Country:US
Mailing Address - Phone:505-416-8009
Mailing Address - Fax:
Practice Address - Street 1:1300 LUISA ST STE 7
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4177
Practice Address - Country:US
Practice Address - Phone:505-416-8009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program