Provider Demographics
NPI:1902631328
Name:FULLMER, MAX (BS)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:FULLMER
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 PARKRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-1447
Mailing Address - Country:US
Mailing Address - Phone:757-288-8355
Mailing Address - Fax:
Practice Address - Street 1:1077 TAMIAMI TRL N
Practice Address - Street 2:
Practice Address - City:NOKOMIS
Practice Address - State:FL
Practice Address - Zip Code:34275-2163
Practice Address - Country:US
Practice Address - Phone:941-486-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAST1364237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist