Provider Demographics
NPI:1841434941
Name:FULLER PRIMARY CARE PLLC
Entity type:Organization
Organization Name:FULLER PRIMARY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:336-382-9494
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:MC LEANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27301-0459
Mailing Address - Country:US
Mailing Address - Phone:336-697-1550
Mailing Address - Fax:336-697-1580
Practice Address - Street 1:5405 FRIEDENS CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:MCLEANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27301-0459
Practice Address - Country:US
Practice Address - Phone:336-382-9494
Practice Address - Fax:336-697-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200909363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2594298AMedicare PIN