Healthcare Provider Details

I. General information

NPI: 1417119652
Provider Name (Legal Business Name): KEVIN S FULLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13135 LEE JACKSON MEMORIAL HWY STE 305
FAIRFAX VA
22033-1907
US

IV. Provider business mailing address

PO BOX 37174
BALTIMORE MD
21297-3174
US

V. Phone/Fax

Practice location:
  • Phone: 703-359-8640
  • Fax: 703-591-6105
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001208
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: