Provider Demographics
NPI:1306397955
Name:POTICHA, SCOTT (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:POTICHA
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28082
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-8082
Mailing Address - Country:US
Mailing Address - Phone:212-987-3100
Mailing Address - Fax:212-731-5210
Practice Address - Street 1:1 GUSTAVE L LEVY PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-241-5561
Practice Address - Fax:212-426-5054
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY431063363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04662406Medicaid
NY04662406Medicaid