Provider Demographics
NPI:1851988745
Name:FULLGRAF, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:FULLGRAF
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 1:3947 LENNANE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-1971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3947 LENNANE DR STE 110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1971
Practice Address - Country:US
Practice Address - Phone:916-283-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-25
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV78707146L00000X
NVCHW1-5089172V00000X
NVPRSS-INT-5020175T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist