Healthcare Provider Details

I. General information

NPI: 1558306209
Provider Name (Legal Business Name): MAUREEN PENDERGAST FULLER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SOUTH ST
WARE MA
01082-1625
US

IV. Provider business mailing address

5220 BELFORT RD STE 130
JACKSONVILLE FL
32256-6018
US

V. Phone/Fax

Practice location:
  • Phone: 413-967-2268
  • Fax: 413-967-2548
Mailing address:
  • Phone: 904-446-3686
  • Fax: 904-446-3032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1366
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: