Provider Demographics
NPI:1811038011
Name:FULLER, ROBIN H (PA C)
Entity Type:Individual
Prefix:MR
First Name:ROBIN
Middle Name:H
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA C
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Mailing Address - Street 1:17 LANSING ST
Mailing Address - Street 2:AMMS, PC
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-252-0000
Mailing Address - Fax:315-252-0070
Practice Address - Street 1:37 W GARDEN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-2662
Practice Address - Country:US
Practice Address - Phone:315-252-0000
Practice Address - Fax:315-252-0070
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2016-09-16
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Provider Licenses
StateLicense IDTaxonomies
NY003118363AS0400X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02903446Medicaid