Basic Information
| Provider Information | |||||||||
| NPI: | 1871546226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 MEDICAL PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032553422 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Practice Location | |||||||||
| Address1: | 2638 TWO NOTCH RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292041454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032562500 | ||||||||
| FaxNumber: | 8032553451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APN1042 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | NP0171 | 05 | SC | MEDICAID |