Basic Information
| Provider Information | |||||||||
| NPI: | 1295058717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | ERINN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | 5742376069 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 MEMORIAL DR STE 302 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5743673800 | ||||||||
| FaxNumber: | 5743673801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2010 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001520A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 300005961 | 05 | IN | MEDICAID |