Provider Demographics
NPI:1639754294
Name:FULLER, ANNE (PA)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 612526
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-2526
Mailing Address - Country:US
Mailing Address - Phone:972-256-3700
Mailing Address - Fax:866-630-6348
Practice Address - Street 1:3501 N MACARTHUR BLVD STE 500
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3675
Practice Address - Country:US
Practice Address - Phone:972-256-3700
Practice Address - Fax:866-630-6348
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant