Provider Demographics
NPI:1396765475
Name:FULLER, EDWIN S (CRNA)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:S
Last Name:FULLER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:TURNERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30580-0369
Mailing Address - Country:US
Mailing Address - Phone:706-839-6205
Mailing Address - Fax:706-754-9668
Practice Address - Street 1:541 HISTORIC HWY 441 NORTH
Practice Address - Street 2:
Practice Address - City:DEMOREST
Practice Address - State:GA
Practice Address - Zip Code:30535
Practice Address - Country:US
Practice Address - Phone:706-839-6205
Practice Address - Fax:706-754-9668
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR105765367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00550734CMedicaid
GA000550734EMedicaid
GA43ZCBTMMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID
GA511I430296Medicare PIN