Provider Demographics
NPI:1578824157
Name:FULLER, MAREN YNGVE (MD)
Entity Type:Individual
Prefix:
First Name:MAREN
Middle Name:YNGVE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAREN
Other - Middle Name:
Other - Last Name:YNGVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:MGJ9-002
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2358
Practice Address - Country:US
Practice Address - Phone:832-824-6422
Practice Address - Fax:832-825-0164
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10044080207ZP0102X
TXQ7872207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty