Provider Demographics
NPI:1780103820
Name:FULLER, KELBY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:KELBY
Middle Name:LEE
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 1:726 WHISPER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:THURMOND
Mailing Address - State:NC
Mailing Address - Zip Code:28683-9467
Mailing Address - Country:US
Mailing Address - Phone:336-469-4662
Mailing Address - Fax:
Practice Address - Street 1:726 WHISPER RIDGE LN
Practice Address - Street 2:
Practice Address - City:THURMOND
Practice Address - State:NC
Practice Address - Zip Code:28683-9467
Practice Address - Country:US
Practice Address - Phone:336-469-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant