Provider Demographics
NPI:1215549456
Name:POTTER, CHRISTINA MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIA
Last Name: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 1:5 CINEMA DR UNIT 22
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1634
Mailing Address - Country:US
Mailing Address - Phone:585-953-2445
Mailing Address - Fax:
Practice Address - Street 1:740 S MEADOW ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5377
Practice Address - Country:US
Practice Address - Phone:607-319-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025510363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant