Provider Demographics
NPI:1518030121
Name:BLAIR-POTTINGER, SHARON (PA)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BLAIR-POTTINGER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13805 SW 264TH ST
Mailing Address - Street 2:
Mailing Address - City:NARANJA
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7602
Mailing Address - Country:US
Mailing Address - Phone:305-258-6813
Mailing Address - Fax:305-258-9858
Practice Address - Street 1:10300 SW 216TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1003
Practice Address - Country:US
Practice Address - Phone:305-253-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290323700Medicaid
FLS54667Medicare UPIN
E0639Medicare PIN