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General NPI Number Information
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NPI Number | 1558306209
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Entity Type | Individual
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Provider Name | MAUREEN PENDERGAST FULLER P.A.
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Gender | Female
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Dates
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Enumeration Date | 06/17/2006
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 85 SOUTH ST
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City | WARE
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State | MA
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Zip | 01082-1625
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Country | US
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Telephone | 413-967-2268
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Fax | 413-967-2548
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Provider Business Mailing Address
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Address Line | 5220 BELFORT RD STE 130
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City | JACKSONVILLE
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State | FL
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Zip | 32256-6018
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Country | US
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Telephone | 904-446-3686
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Fax | 904-446-3032
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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 | 1366
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License Number State | MA
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