Provider Demographics
NPI:1275686669
Name:FULLMER, CAROLYN STARR (PAC)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:STARR
Last Name:FULLMER
Suffix:
Gender:F
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 137
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109-0137
Mailing Address - Country:US
Mailing Address - Phone:509-935-8711
Mailing Address - Fax:509-935-4882
Practice Address - Street 1:410 E KING ST
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109-0137
Practice Address - Country:US
Practice Address - Phone:509-935-8711
Practice Address - Fax:509-935-4882
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8511230Medicaid
WA0159376OtherWA STATE L&I
WAPA10003285OtherWA STATE LICENSE
WA0159376OtherWA STATE L&I
WAPA10003285OtherWA STATE LICENSE