Provider Demographics
NPI:1396177556
Name:RAE FULTON, STEPHANIE ELIZABETH (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:RAE FULTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4800 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1176
Mailing Address - Country:US
Mailing Address - Phone:248-673-0500
Mailing Address - Fax:248-673-6077
Practice Address - Street 1:4800 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1176
Practice Address - Country:US
Practice Address - Phone:248-673-0500
Practice Address - Fax:248-673-6077
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006793OtherLICENSE#