Provider Demographics
NPI:1295863587
Name:FULLER, DONALD JENKINS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JENKINS
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 - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216A BALDWIN MILL RD
Mailing Address - Street 2:
Mailing Address - City:JARRETTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21084-1908
Mailing Address - Country:US
Mailing Address - Phone:410-557-8389
Mailing Address - Fax:
Practice Address - Street 1:401 N BROADWAY
Practice Address - Street 2:RM 1360 WEINBERG BLDG.
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1146
Practice Address - Country:US
Practice Address - Phone:410-955-8742
Practice Address - Fax:410-502-1746
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000378363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical