Provider Demographics
NPI:1497776132
Name:FULLER, JAMES EVANS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EVANS
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 NORTH DECATUR RD.
Mailing Address - Street 2:#166
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:
Practice Address - Street 1:2107 N DECATUR RD
Practice Address - Street 2:#166
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5305
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001998363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical