Individual
MR. KEVIN S FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
13135 LEE JACKSON MEMORIAL HWY STE 305, FAIRFAX, VA 22033-1907
(703) 359-8640
(703) 591-6105
Mailing address
PO BOX 37174, BALTIMORE, MD 21297-3174
(571) 423-5699
(571) 423-5698
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0110001208
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0110001208
LICENSE NUMBER
VA
05
—
1417119652
—
VA
Enumeration date
06/30/2008
Last updated
04/21/2021
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