MEDICARE: RANDALL B FULFORD 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	004674	GA
2	363A00000X	Physician Assistant	PA3183	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	01157676	OTHER	GA	AMERIGROUP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295795896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL B FULFORD PA-C

Provider Business Mailing Address
First Line	:	7131 KING ARTHUR RD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-4108
Country	:	US
Telephone Number	:	904-338-1193
Fax Number	:

Provider Business Practice Location Address
First Line	:	96279 BRADY POINT RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-7076
Country	:	US
Telephone Number	:	904-321-0088
Fax Number	:

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	02/01/2017

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