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General NPI Number Information
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NPI Number | 1417119652
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Entity Type | Individual
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Provider Name | KEVIN S FULLER PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/30/2008
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Last Update Date | 04/21/2021
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Provider Practice Location Address
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Address Line | 13135 LEE JACKSON MEMORIAL HWY STE 305
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City | FAIRFAX
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State | VA
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Zip | 22033-1907
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Country | US
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Telephone | 703-359-8640
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Fax | 703-591-6105
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Provider Business Mailing Address
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Address Line | PO BOX 37174
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City | BALTIMORE
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State | MD
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Zip | 21297-3174
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Country | US
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Telephone | 571-423-5699
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Fax | 571-423-5698
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0110001208
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License Number State | VA
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