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General NPI Number Information
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NPI Number | 1497128235
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Entity Type | Individual
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Provider Name | AUDRA FULLER PA-C
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Gender | Female
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Dates
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Enumeration Date | 11/02/2015
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Last Update Date | 08/20/2025
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Provider Practice Location Address
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Address Line | 125 BAPTIST WAY STE 5C
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City | PENSACOLA
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State | FL
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Zip | 32503-2274
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Country | US
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Telephone | 448-227-6950
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 95590
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-0590
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Country | US
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Telephone | 801-352-9500
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Fax | 801-352-7976
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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 | PA9115779
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085.005515
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.005450
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License Number State | CO
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