Provider Demographics
NPI:1538119789
Name:POTTS, COREY A (CRNA)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:POTTS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:1808 SHERMAN DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IN
Practice Address - Zip Code:47670
Practice Address - Country:US
Practice Address - Phone:812-385-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162089A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00219322OtherRAILROAD MEDICARE
IN200510270Medicaid
IN000000353810OtherBLUE SHIELD
000000682757OtherANTHEM
P00219322OtherRAILROAD MEDICARE
INM100030911Medicare PIN
IN200510270Medicaid