Provider Demographics
NPI:1134294036
Name:POTTS, ROBERT T (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:T
Last Name:POTTS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-2316
Mailing Address - Country:US
Mailing Address - Phone:304-845-2500
Mailing Address - Fax:304-845-2624
Practice Address - Street 1:1307 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-2316
Practice Address - Country:US
Practice Address - Phone:304-845-2500
Practice Address - Fax:304-845-2624
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00948363A00000X
OH50001843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000353890OtherANTHEM BCBS
231646OtherADVANTRA CARELINK
P00399683OtherRR MEDCR
OHPA23661Medicare PIN
OH9348211Medicare PIN
Q26641Medicare UPIN
WVPOPA25131Medicare PIN
WV9350501Medicare PIN