Provider Demographics
NPI:1306944053
Name:FULLER, PAULA KNOD (CRNA)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:KNOD
Last Name:FULLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 QUAPAW TRL
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-5856
Mailing Address - Country:US
Mailing Address - Phone:501-416-0687
Mailing Address - Fax:
Practice Address - Street 1:9601 INTERSTATE 630 EXIT 7
Practice Address - Street 2:EXIT 7
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7202
Practice Address - Country:US
Practice Address - Phone:501-202-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00893207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR138802701Medicaid
AR5S572Medicare PIN
AR430077471Medicare PIN