Provider Demographics
NPI:1124015102
Name:FULLER, CHUCK B (PA-C)
Entity Type:Individual
Prefix:
First Name:CHUCK
Middle Name:B
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:660 SHOSHONE ST E
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6110
Mailing Address - Country:US
Mailing Address - Phone:208-732-3400
Mailing Address - Fax:208-732-3300
Practice Address - Street 1:660 SHOSHONE ST E
Practice Address - Street 2:SUITE 130
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6110
Practice Address - Country:US
Practice Address - Phone:208-732-3400
Practice Address - Fax:208-732-3300
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147741OtherREGENCE BLUE SHIELD IND #
IDPAQR4OtherBLUE CROSS IND #
ID1666096Medicare ID - Type UnspecifiedMEDICARE IND #
ID16660961Medicare PIN