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NPI Code Detail

MEDICARE: MRS. MAUREEN PENDERGAST FULLER P.A.

MEDICARE: MRS. MAUREEN PENDERGAST FULLER P.A.
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
1363A00000XPhysician Assistant1366MA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1M15170OTHERMABCBS

General Provider Information

NPI Number : 1558306209
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MAUREEN PENDERGAST FULLER P.A.
Provider Business Mailing Address
First Line : 5220 BELFORT RD STE 130
Second Line :
City : JACKSONVILLE
State : FL
Zip : 32256-6018
Country : US
Telephone Number : 904-446-3686
Fax Number : 904-446-3032
Provider Business Practice Location Address
First Line : 85 SOUTH ST
Second Line :
City : WARE
State : MA
Zip : 01082-1625
Country : US
Telephone Number : 413-967-2268
Fax Number : 413-967-2548
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/17/2006
Last Update Date : 09/10/2020

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