Healthcare Provider Details

I. General information

NPI: 1376926352
Provider Name (Legal Business Name): JESSICA FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD MEDSTAR SOUTHERN MD HOSPITAL CENTER EMERGENCY DEPT
CLINTON MD
20735-3358
US

IV. Provider business mailing address

3205 OX MEADOW CT
OAK HILL VA
20171-1747
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-8000
  • Fax:
Mailing address:
  • Phone: 703-626-2412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0005818
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: