Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208200000X | Surgeon | MD420734 | PA |
N | 208600000X | Surgeon | MD420734 | PA |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | MD420734 | PA |
NPI | 1013115930 |
---|---|
Provider Name | Stephanie Fuller |
First Address | Philadelphia, PA 19107-3323 |
Second Address | Philadelphia, PA 19104-4399 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/07/2007 |
Last Update Date | 11/04/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100743887-0030 | (05) | PA |