Provider Demographics
NPI:1871546226
Name:FULLER, SARA G (NP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:G
Last Name:FULLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:15 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8003
Mailing Address - Country:US
Mailing Address - Phone:803-255-3422
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:2638 TWO NOTCH RD
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1454
Practice Address - Country:US
Practice Address - Phone:803-256-2500
Practice Address - Fax:803-255-3451
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCAPN1042363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0171Medicaid
S924366580Medicare ID - Type Unspecified
SCS924366580Medicare PIN
SCNP0171Medicaid