Jack G. Fuller, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

PA12536 Issued in CA

Practice address

1225 Wilshire Boulevard
Los Angeles, CA 90017-2395

Phone

(213) 977-2423

Fax

(213) 202-7028

NPI assigned

May 18, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147910400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183939200000",
    "number": "1376596668",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2550 NORTHHOLLYWOOD WAY",
            "address_2": "SUITE 209",
            "city": "BURBANK",
            "state": "CA",
            "postal_code": "915055019",
            "telephone_number": "818-557-0135",
            "fax_number": "818-557-1394"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1225 WILSHIRE BOULEVARD",
            "city": "LOS ANGELES",
            "state": "CA",
            "postal_code": "900172395",
            "telephone_number": "213-977-2423",
            "fax_number": "213-202-7028"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FULLER",
        "first_name": "JACK",
        "middle_name": "G.",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-05-18",
        "last_updated": "2007-07-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA12536",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GOOD SAMARITAN RAILROAD",
            "identifier": "P00198638",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "PA12536",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Christina Fuller
• Claire V. Fuller, MD
• Clark Beeman Fuller, M.D.
• David Lee Fuller II, M.D.
• Deborah Fuller, MA
• Jennifer Elizabeth Fuller, PT
• Laura Marie Fuller, MFT INTERN
• M. Camille Fuller, D.D.S.
• Myesha Fuller, CMT
• Perry Fuller

• Physician Assistant in Los Angeles, CA
• Providers in Los Angeles, CA by specialty
• Physician Assistant in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.