Provider Demographics
NPI:1487961231
Name:FULLER, TRACI ANN (PA)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:ANN
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:ANN
Other - Last Name:FULLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6480 HARRISON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7961
Mailing Address - Country:US
Mailing Address - Phone:513-354-3700
Mailing Address - Fax:513-354-7651
Practice Address - Street 1:6480 HARRISON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45247-7961
Practice Address - Country:US
Practice Address - Phone:513-354-3700
Practice Address - Fax:513-354-7651
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006385363AM0700X, 363AS0400X
OH50003781363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50003781OtherMEDICAL LICENSE
GA006385OtherSTATE MEDICAL LICENSE