Provider Demographics
NPI:1427002716
Name:FULLER, PATRICK J (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:FULLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 E WEBSTER PL
Mailing Address - Street 2:#301
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4256
Mailing Address - Country:US
Mailing Address - Phone:414-272-7009
Mailing Address - Fax:414-272-6261
Practice Address - Street 1:2524 E WEBSTER PL
Practice Address - Street 2:ST #301
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4256
Practice Address - Country:US
Practice Address - Phone:414-272-7009
Practice Address - Fax:414-272-6261
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36676208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32183000Medicaid
G40092Medicare UPIN
WI02975002Medicare ID - Type Unspecified