Provider Demographics
NPI:1386994408
Name:FULLER, TRACY C (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:C
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT: PHYSICIAN ASSISTANTS
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT: PHYSICIAN ASSISTANTS
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1718
Practice Address - Country:US
Practice Address - Phone:847-570-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.004406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant