MEDICARE: LATOYIA DASHAWN FULLER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9111028	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245739119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATOYIA DASHAWN FULLER PA-C

Provider Business Mailing Address
First Line	:	1770 EAGLE TRACE BLVD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-7817
Country	:	US
Telephone Number	:	317-223-1056
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 EAGLE TRACE BLVD
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-7817
Country	:	US
Telephone Number	:	317-223-1056
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2018
Last Update Date	:	02/06/2018

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