Provider Demographics
NPI:1093715674
Name:HULL, TODD CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:CHARLES
Last Name:HULL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7744 BAY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3427
Mailing Address - Country:US
Mailing Address - Phone:772-589-0331
Mailing Address - Fax:
Practice Address - Street 1:7744 BAY ST STE 2
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3427
Practice Address - Country:US
Practice Address - Phone:772-589-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT371363AS0400X
FLPA9110158363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP00163692OtherRR MEDICARE
MT4303728Medicaid
MT000900853OtherBLUECROSS BLUESHIELD
MT4303728Medicaid
MT000084007Medicare PIN
MT0500560001Medicare NSC