Provider Demographics
NPI:1396076634
Name:FULLER, CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:WENTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:14123 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-2013
Mailing Address - Country:US
Mailing Address - Phone:443-838-7883
Mailing Address - Fax:
Practice Address - Street 1:2100 SE SALERNO RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-6503
Practice Address - Country:US
Practice Address - Phone:772-223-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004109363A00000X
FLPA9115395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00266Medicare PIN