Provider Demographics
NPI:1275763815
Name:POTTER, CHERYL (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
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 1:1400 PRESSLER STREET
Mailing Address - Street 2:UNIT 1461
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3722
Mailing Address - Country:US
Mailing Address - Phone:713-563-9342
Mailing Address - Fax:713-792-2586
Practice Address - Street 1:1400 PRESSLER ST
Practice Address - Street 2:UNIT 1461
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3722
Practice Address - Country:US
Practice Address - Phone:713-563-9342
Practice Address - Fax:713-792-2586
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX210123001Medicaid
TX8L25396Medicare PIN