Provider Demographics
NPI:1518357987
Name:POTTER, RANDALL (RT(R))
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 FERNWOOD DR # A
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-6402
Mailing Address - Country:US
Mailing Address - Phone:805-765-5347
Mailing Address - Fax:
Practice Address - Street 1:1385 FERNWOOD DR # A
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-6402
Practice Address - Country:US
Practice Address - Phone:805-765-5347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF00104187247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist