Provider Demographics
NPI:1366888752
Name:FULLER, ADDISON DEITRICH (MD)
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:DEITRICH
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALISON
Other - Middle Name:DEIRDRE
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:257 BILTMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4120
Mailing Address - Country:US
Mailing Address - Phone:828-285-0622
Mailing Address - Fax:
Practice Address - Street 1:257 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4120
Practice Address - Country:US
Practice Address - Phone:828-285-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00011207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine