Basic Information
| Provider Information | |||||||||
| NPI: | 1487958625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATUSHEVSKI | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12011 LEE JACKSON MEMORIAL HIGHWAY | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033912031 | ||||||||
| FaxNumber: | 7032733943 | ||||||||
| Practice Location | |||||||||
| Address1: | 20905 PROFESSIONAL PLAZA | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | ASHBURN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037260003 | ||||||||
| FaxNumber: | 7037266444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2011 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0110003507 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.