Provider Demographics
NPI:1265944227
Name:FULLER, COURTNEY R (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:R
Last Name:FULLER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 PARAMOUNT DR STE 205
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-5416
Mailing Address - Country:US
Mailing Address - Phone:508-996-3991
Mailing Address - Fax:
Practice Address - Street 1:675 PARAMOUNT DR STE 205
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5416
Practice Address - Country:US
Practice Address - Phone:617-798-6500
Practice Address - Fax:617-798-6500
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant