Individual
MRS. MAUREEN PENDERGAST FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
85 SOUTH ST, WARE, MA 01082-1625
(413) 967-2268
(413) 967-2548
Mailing address
5220 BELFORT RD STE 130, JACKSONVILLE, FL 32256-6018
(904) 446-3686
(904) 446-3032
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1366
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
M15170
BCBS
MA
Enumeration date
06/17/2006
Last updated
09/10/2020
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