Provider Demographics
NPI:1043255821
Name:FULLER, KARL R (PA)
Entity Type:Individual
Prefix:MR
First Name:KARL
Middle Name:R
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1275 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1820
Mailing Address - Country:US
Mailing Address - Phone:413-785-1153
Mailing Address - Fax:413-781-4951
Practice Address - Street 1:1275 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-1820
Practice Address - Country:US
Practice Address - Phone:413-785-1153
Practice Address - Fax:413-781-4951
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15170OtherBCBS
MAM15170OtherBCBS