Basic Information
| Provider Information | |||||||||
| NPI: | 1104184191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6621 FANNIN ST STE A3300 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302373 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6621 FANNIN ST STE A3300 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8328241000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | BP10042968 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.