Provider Demographics
NPI:1073793691
Name:FULLER, BERTRAM (PAC)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4808
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-1808
Mailing Address - Country:US
Mailing Address - Phone:562-927-0677
Mailing Address - Fax:
Practice Address - Street 1:7033 STEWART AND GRAY RD UNIT 38
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-4355
Practice Address - Country:US
Practice Address - Phone:562-927-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14719363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicare PIN