Provider Demographics
NPI:1295058717
Name:FULLER, ERINN C (PA-C)
Entity type:Individual
Prefix:
First Name:ERINN
Middle Name:C
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 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-2129
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:3221 BEACON PARKWAY
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7196
Practice Address - Country:US
Practice Address - Phone:574-647-1670
Practice Address - Fax:574-647-6927
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001520A363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005961Medicaid
IL085003695Medicaid
IL085003695Medicaid