Provider Demographics
NPI:1639723240
Name:FULLER, MARY CASSANDRA (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CASSANDRA
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:29710 TWIN CREEKS DR
Mailing Address - Street 2:
Mailing Address - City:BULVERDE
Mailing Address - State:TX
Mailing Address - Zip Code:78163-2406
Mailing Address - Country:US
Mailing Address - Phone:210-831-7107
Mailing Address - Fax:
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-692-0831
Practice Address - Fax:210-593-0211
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142325363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily