Provider Demographics
NPI:1376654319
Name:POTTS, ERIC MICHEAL (PAC)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:MICHEAL
Last Name:POTTS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1038
Mailing Address - Country:US
Mailing Address - Phone:812-885-3810
Mailing Address - Fax:812-885-3811
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-885-3810
Practice Address - Fax:812-885-3811
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85002740363A00000X
NC0010-00966363A00000X
IN10001155A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2771184Medicare PIN
Q72454Medicare UPIN
IN941140S4Medicare PIN