Provider Demographics
NPI:1144583451
Name:FULLER, NATHANAEL KEITH (PA)
Entity Type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:KEITH
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:IA
Mailing Address - Zip Code:51455-1005
Mailing Address - Country:US
Mailing Address - Phone:712-655-2072
Mailing Address - Fax:712-655-3228
Practice Address - Street 1:1550 6TH STREET
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:IA
Practice Address - Zip Code:51455-1004
Practice Address - Country:US
Practice Address - Phone:712-655-2072
Practice Address - Fax:712-655-3228
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical