Provider Demographics
NPI:1417119652
Name:FULLER, KEVIN S (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:S
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:13135 LEE JACKSON MEMORIAL HWY STE 305
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1907
Practice Address - Country:US
Practice Address - Phone:703-359-8640
Practice Address - Fax:703-591-6105
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110001208OtherLICENSE NUMBER
VA1417119652Medicaid