Provider Demographics
NPI:1407839079
Name:POTTS, MATTHEW RAY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RAY
Last Name:POTTS
Suffix:
Gender:M
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 1:4601 PARK RD
Mailing Address - Street 2:STE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2276
Mailing Address - Fax:704-945-7681
Practice Address - Street 1:354 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2402
Practice Address - Country:US
Practice Address - Phone:704-786-5122
Practice Address - Fax:704-782-8279
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0001-04182363AS0400X
NC104182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA215715106AMedicaid
GA215715106BMedicaid
GA215715106DMedicaid
GA215715106CMedicaid
GA215715106EMedicaid
GA215715106EMedicaid
GA202I974818Medicare PIN