Provider Demographics
NPI:1174633994
Name:WANDERER-POTTER, LYNN A (PA-C)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:WANDERER-POTTER
Suffix:
Gender:F
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 1:10521 E SPRING CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-8824
Mailing Address - Country:US
Mailing Address - Phone:505-350-5766
Mailing Address - Fax:
Practice Address - Street 1:6739 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5311
Practice Address - Country:US
Practice Address - Phone:202-455-0013
Practice Address - Fax:623-889-0814
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7762363A00000X
NM93-PA25207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH4711Medicaid
343632101Medicare PIN
NMH4711Medicaid