Provider Demographics
NPI:1922381219
Name:FILLERUP, CHRIS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:FILLERUP
Suffix:
Gender:M
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 1:1412 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7639
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:817-702-8445
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3431
Practice Address - Fax:817-927-3603
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015091363A00000X
TXPA09671363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03436853Medicaid
NY03436853Medicaid