Provider Demographics
NPI:1487958625
Name:FULLER, KRISTIN L (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LEIGH
Other - Last Name:MATUSHEVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12011 LEE JACKSON MEMORIAL HIGHWAY
Mailing Address - Street 2:SUITE 504
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3315
Mailing Address - Country:US
Mailing Address - Phone:703-391-2031
Mailing Address - Fax:703-273-3943
Practice Address - Street 1:20905 PROFESSIONAL PLAZA
Practice Address - Street 2:SUITE 330
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147
Practice Address - Country:US
Practice Address - Phone:703-726-0003
Practice Address - Fax:703-726-6444
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
VA0110003507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical