Provider Demographics
NPI:1508019639
Name:POTVIN, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:POTVIN
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 1:5619 LOON DR
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8984
Mailing Address - Country:US
Mailing Address - Phone:612-598-6626
Mailing Address - Fax:
Practice Address - Street 1:5619 LOON DR
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-8984
Practice Address - Country:US
Practice Address - Phone:612-598-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications