Provider Demographics
NPI:1558306209
Name:FULLER, MAUREEN PENDERGAST (PA)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:PENDERGAST
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5220 BELFORT RD STE 130
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6018
Mailing Address - Country:US
Mailing Address - Phone:904-446-3686
Mailing Address - Fax:904-446-3032
Practice Address - Street 1:85 SOUTH ST
Practice Address - Street 2:
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1625
Practice Address - Country:US
Practice Address - Phone:413-967-2268
Practice Address - Fax:413-967-2548
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15170OtherBCBS
MAAP1575Medicare ID - Type Unspecified