Provider Demographics
NPI:1992159644
Name:FULLMER, ERIK DEE (CADC CANIDATE)
Entity type:Individual
Prefix:MR
First Name:ERIK
Middle Name:DEE
Last Name:FULLMER
Suffix:
Gender:M
Credentials:CADC CANIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 SE 5TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4095
Mailing Address - Country:US
Mailing Address - Phone:503-648-5269
Mailing Address - Fax:503-648-5269
Practice Address - Street 1:134 SE 5TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4095
Practice Address - Country:US
Practice Address - Phone:503-648-5269
Practice Address - Fax:503-648-5269
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278095Medicaid