Healthcare Provider Details

I. General information

NPI: 1811038011
Provider Name (Legal Business Name): ROBIN H FULLER PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 W GARDEN ST SUITE 105
AUBURN NY
13021-2662
US

IV. Provider business mailing address

17 LANSING ST AMMS, PC
AUBURN NY
13021-1983
US

V. Phone/Fax

Practice location:
  • Phone: 315-252-0000
  • Fax: 315-252-0070
Mailing address:
  • Phone: 315-252-0000
  • Fax: 315-252-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003118
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: