Provider Demographics
NPI:1528366051
Name:FULLERTON, EMILY REBECCA (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:REBECCA
Last Name:FULLERTON
Suffix:
Gender:F
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 1:190 OUTER MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-2324
Mailing Address - Country:US
Mailing Address - Phone:315-265-9271
Mailing Address - Fax:315-265-4206
Practice Address - Street 1:190 OUTER MAIN ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-2324
Practice Address - Country:US
Practice Address - Phone:315-265-9271
Practice Address - Fax:315-265-4206
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant