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Individual
TRACI ANN FULLER
Active
Individual
TRACI ANN FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
006385
GA
363AS0400X
Surgical Physician Assistant
006385
GA
363AS0400X
Surgical Physician Assistant
Primary
50003781
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
006385
STATE MEDICAL LICENSE
GA
01
—
50003781
MEDICAL LICENSE
OH
Enumeration date
08/31/2010
Last updated
06/21/2013
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