Provider Demographics
NPI:1306862164
Name:POTTER, CRAIG HOWARD
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:HOWARD
Last Name:POTTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2737
Mailing Address - Country:US
Mailing Address - Phone:218-786-3500
Mailing Address - Fax:218-786-3513
Practice Address - Street 1:4212 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2737
Practice Address - Country:US
Practice Address - Phone:218-786-3500
Practice Address - Fax:218-786-3513
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS47938Medicare UPIN
MN970001706Medicare PIN