Provider Demographics
NPI:1851310494
Name:FULLER, ROBYN L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ROBYN
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67555 E PALM CANYON DR STE C113
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-5412
Mailing Address - Country:US
Mailing Address - Phone:760-770-1277
Mailing Address - Fax:760-328-2191
Practice Address - Street 1:67555 E PALM CANYON DR STE C113
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-5412
Practice Address - Country:US
Practice Address - Phone:760-770-1277
Practice Address - Fax:760-328-2191
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17873363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPA178730Medicare UPIN
CAQ43298Medicare UPIN