Provider Demographics
NPI:1720272073
Name:FULLER, LANCE ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:ROBERT
Last Name:FULLER
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Gender:M
Credentials:MD
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Mailing Address - Street 1:893 HWY 70 WEST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2597
Mailing Address - Country:US
Mailing Address - Phone:919-779-6461
Mailing Address - Fax:800-881-4493
Practice Address - Street 1:893 HWY 70 WEST
Practice Address - Street 2:SUITE 200
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2597
Practice Address - Country:US
Practice Address - Phone:919-779-6461
Practice Address - Fax:800-881-4493
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2015-09-03
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Provider Licenses
StateLicense IDTaxonomies
NC2007-010832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC52165BMedicare UPIN
NCNC0568AMedicare PIN