Provider Demographics
NPI:1457349144
Name:FULLAN, DEBRA (DO)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:FULLAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 W TILGHMAN ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-9130
Mailing Address - Country:US
Mailing Address - Phone:484-866-9583
Mailing Address - Fax:610-366-1147
Practice Address - Street 1:4905 W TILGHMAN ST
Practice Address - Street 2:SUITE 250
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9130
Practice Address - Country:US
Practice Address - Phone:484-866-9583
Practice Address - Fax:610-366-1147
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007883L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1105125OtherKEYSTONE MERCY
PA01749864OtherGATEWAY
PA0017498640Medicaid
PA000000097909OtherTHREE RIVERS
PA0671239000OtherINDEP. BLUE CROSS
PA1105125OtherAMERIHEALTH MERCY
PA163943OtherHIGHMARK
PA0163943OtherKHP CENTRAL
PAF66643Medicare UPIN
PA026988EU8Medicare PIN
PA1105125OtherAMERIHEALTH MERCY