Provider Demographics
NPI:1336217702
Name:FULLER, MICHAEL W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:FULLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7000 W PLANO PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8466
Mailing Address - Country:US
Mailing Address - Phone:214-483-9300
Mailing Address - Fax:214-483-9301
Practice Address - Street 1:7000 W PLANO PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8466
Practice Address - Country:US
Practice Address - Phone:214-483-9300
Practice Address - Fax:214-483-9301
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02147363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201918401Medicaid
TX201918401Medicaid
TX8N4927Medicare PIN