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NPI Code Detail

MEDICARE: MR. JACK G. FULLER PA-C

MEDICARE: MR. JACK G. FULLER PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA12536CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1P00198638OTHERCAGOOD SAMARITAN RAILROAD
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1376596668
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JACK G. FULLER PA-C
Provider Business Mailing Address
First Line : 2550 NORTHHOLLYWOOD WAY
Second Line : SUITE 209
City : BURBANK
State : CA
Zip : 91505-5019
Country : US
Telephone Number : 818-557-0135
Fax Number : 818-557-1394
Provider Business Practice Location Address
First Line : 1225 WILSHIRE BOULEVARD
Second Line :
City : LOS ANGELES
State : CA
Zip : 90017-2395
Country : US
Telephone Number : 213-977-2423
Fax Number : 213-202-7028
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/18/2006
Last Update Date : 07/09/2007

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