Provider Demographics
NPI:1104838101
Name:POTTER, PAUL EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWARD
Last Name:POTTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 S 76TH CT
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4383
Mailing Address - Country:US
Mailing Address - Phone:402-430-4716
Mailing Address - Fax:402-464-6142
Practice Address - Street 1:770 N COTNER BLVD
Practice Address - Street 2:STE 125
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2377
Practice Address - Country:US
Practice Address - Phone:402-464-6141
Practice Address - Fax:402-464-6142
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE09118OtherBLUE CROSS/BLUE SHIELD
NE09118OtherBLUE CROSS/BLUE SHIELD