Provider Demographics
NPI:1215137591
Name:FULLER, BRIANNA KATHERINE (PA)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:KATHERINE
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2907
Mailing Address - Country:US
Mailing Address - Phone:518-758-6101
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534
Practice Address - Country:US
Practice Address - Phone:518-758-6101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY012528OtherLICENSE