LANCE ROBERT FULLER MD Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125048313

License Status

CANCELLED

Business

First Name

LANCE

Middle

ROBERT

Last Name

FULLER

Suffix

Business Name

LANCE ROBERT FULLER MD

Original Issue Date

07/01/2004

Effective Date

07/01/2004

Expiration Date

06/30/2007

City

NORTH CHICAGO

State

Zip

60064

County

LAKE

Specialty/Qualifier

Psychiatry

Ever Disciplined

LastModifiedDate

09/22/2006