Provider Demographics
NPI:1164016523
Name:POTEET, MANSON (PTA)
Entity Type:Individual
Prefix:
First Name:MANSON
Middle Name:
Last Name:POTEET
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 RIDGEWAY CT
Mailing Address - Street 2:
Mailing Address - City:FERDINAND
Mailing Address - State:IN
Mailing Address - Zip Code:47532-9572
Mailing Address - Country:US
Mailing Address - Phone:615-917-5301
Mailing Address - Fax:
Practice Address - Street 1:1712 LELAND DR
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-4754
Practice Address - Country:US
Practice Address - Phone:812-683-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006025A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant