Provider Demographics
NPI:1366331142
Name:FULLER, AUDREY MIRIAM (PA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:MIRIAM
Last Name:FULLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 STAGS LEAP APT 4077
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6909
Mailing Address - Country:US
Mailing Address - Phone:717-513-6027
Mailing Address - Fax:
Practice Address - Street 1:997 HAMPSHIRE LN
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-8105
Practice Address - Country:US
Practice Address - Phone:972-479-0400
Practice Address - Fax:972-479-9435
Is Sole Proprietor?:No
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEMPORARY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant