Provider Demographics
NPI:1033569223
Name:POTERUCHA, AUDRA LEIGH (DO)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:LEIGH
Last Name:POTERUCHA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S 19TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:IA
Mailing Address - Zip Code:50201-2902
Mailing Address - Country:US
Mailing Address - Phone:515-382-5413
Mailing Address - Fax:515-382-7107
Practice Address - Street 1:640 S 19TH ST STE 100
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:IA
Practice Address - Zip Code:50201-2902
Practice Address - Country:US
Practice Address - Phone:515-382-5413
Practice Address - Fax:515-382-7107
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-05052207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine