Provider Demographics
NPI:1154090603
Name:POTTIEGER, MICHAEL SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:POTTIEGER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1872 BRANDYWINE RD
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-2610
Mailing Address - Country:US
Mailing Address - Phone:610-406-8568
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVENUE
Practice Address - Street 2:MEDICAL SCIENCE BLDG SUITE 275
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096
Practice Address - Country:US
Practice Address - Phone:610-642-1908
Practice Address - Fax:610-642-6806
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA062762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty