Basic Information
| Provider Information | |||||||||
| NPI: | 1992399026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLGRAPP | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4641 TALBOT PL | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342416148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417808018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6110 STATE ROAD 70 E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342039712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417554242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2021 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9114046 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.