Provider Demographics
NPI:1114423738
Name:POTTRUCK, LORAN RAE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:LORAN
Middle Name:RAE
Last Name:POTTRUCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12248 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOKEELIA
Mailing Address - State:FL
Mailing Address - Zip Code:33922-3308
Mailing Address - Country:US
Mailing Address - Phone:239-222-1447
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:239-270-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9235069363L00000X, 363LS0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool