Healthcare Provider Details

I. General information

NPI: 1154364099
Provider Name (Legal Business Name): FREDERICK P FULLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 N CAPITOL ST NE STE 3100
WASHINGTON DC
20002-5686
US

IV. Provider business mailing address

899 N CAPITOL ST NE STE 3100
WASHINGTON DC
20002-5686
US

V. Phone/Fax

Practice location:
  • Phone: 202-673-3355
  • Fax:
Mailing address:
  • Phone: 202-673-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018646
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9860440-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: