Basic Information
| Provider Information | |||||||||
| NPI: | 1922381219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FILLERUP | ||||||||
| FirstName: | CHRIS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 MAY ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761047639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
| FaxNumber: | 8177028445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177023431 | ||||||||
| FaxNumber: | 8179273603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2011 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 015091 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA09671 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03436853 | 05 | NY | MEDICAID |