Provider Demographics
NPI:1245739119
Name:FULLER, LATOYIA DASHAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:LATOYIA
Middle Name:DASHAWN
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LATOYIA
Other - Middle Name:
Other - Last Name:BALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1770 EAGLE TRACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-7817
Mailing Address - Country:US
Mailing Address - Phone:317-223-1056
Mailing Address - Fax:
Practice Address - Street 1:1770 EAGLE TRACE BLVD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-7817
Practice Address - Country:US
Practice Address - Phone:317-223-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant