Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
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Mr. Michael John Fullam, PA

Individual provider Physician Assistant · NPI 1255599163

Mr. Michael John Fullam, PA is a Physician Assistant in Patchogue, New York. Qualified in 1997, 29 years ago. Practices with New York University, a 5,884-clinician group and accepts Medicare assignment. Licensed in New York.

Years since qualifying
29
Licensed in
NY
In the registry since
2008
What do these letters mean?
PA — Physician Assistant
A licensed clinician who examines, diagnoses and treats under a physician's supervision.

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Practice location Address checks out

107 N Ocean Ave
Patchogue, NY 11772-2012
Phone: (631) 654-5004
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X · Licence 006268 (NY)

Record details

NPI number1255599163
Entity typeIndividual (Type 1)
GenderMale
Credentials PA
Sole proprietorNo
NPI enumeratedMay 28, 2008
Last updated in NPPESFebruary 25, 2021
Certification dateFebruary 25, 2021

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 1997 (29 years in practice)
Group practice New York University — 5884 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount
Practice locations2 on file with Medicare

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