Provider Demographics
NPI:1679564819
Name:FULLER, DONNA (PA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
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 1:415 SAMANTHA CT
Mailing Address - Street 2:
Mailing Address - City:GLYNDON
Mailing Address - State:MD
Mailing Address - Zip Code:21071
Mailing Address - Country:US
Mailing Address - Phone:410-833-3626
Mailing Address - Fax:
Practice Address - Street 1:11722 REISTERSTOWN ROAD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136
Practice Address - Country:US
Practice Address - Phone:410-833-5000
Practice Address - Fax:410-833-1433
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS40495Medicare UPIN