Provider Demographics
NPI:1720494040
Name:FULLER, AARON PARK (ATC)
Entity type:Individual
Prefix:MR
First Name:AARON
Middle Name:PARK
Last Name:FULLER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 GREENVILLE BLVD SE STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-6757
Mailing Address - Country:US
Mailing Address - Phone:252-565-8812
Mailing Address - Fax:252-656-8812
Practice Address - Street 1:518 GREENVILLE BLVD SE STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-6757
Practice Address - Country:US
Practice Address - Phone:252-565-8812
Practice Address - Fax:252-656-8812
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer