Provider Demographics
NPI:1558811711
Name:FULLER, ANDREA NICOLE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:NICOLE
Last Name:FULLER
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 1:1985 CENTRAL EXPY N # 120
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5753
Mailing Address - Country:US
Mailing Address - Phone:972-962-9100
Mailing Address - Fax:512-782-9316
Practice Address - Street 1:1411 MAIN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75202-4052
Practice Address - Country:US
Practice Address - Phone:214-749-4657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant