1295058717 NPI number — ERINN C FULLER PA-C

Table of content: ERINN C FULLER PA-C (NPI 1295058717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295058717 NPI number — ERINN C FULLER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
ERINN
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295058717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 HEALTH DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-1380
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-2129
Provider Business Mailing Address Fax Number:
574-237-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3221 BEACON PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46530-7196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-1670
Provider Business Practice Location Address Fax Number:
574-647-6927
Provider Enumeration Date:
03/11/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  10001520A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300005961 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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