Basic Information
Provider Information | |||||||||
NPI: | 1811038011 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FULLER | ||||||||
FirstName: | ROBIN | ||||||||
MiddleName: | H | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17 LANSING ST | ||||||||
Address2: | AMMS, PC | ||||||||
City: | AUBURN | ||||||||
State: | NY | ||||||||
PostalCode: | 130211983 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152520000 | ||||||||
FaxNumber: | 3152520070 | ||||||||
Practice Location | |||||||||
Address1: | 37 W GARDEN ST | ||||||||
Address2: | SUITE 105 | ||||||||
City: | AUBURN | ||||||||
State: | NY | ||||||||
PostalCode: | 130212662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3152520000 | ||||||||
FaxNumber: | 3152520070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2007 | ||||||||
LastUpdateDate: | 09/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 003118 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 02903446 | 05 | NY |   | MEDICAID |