Provider Demographics
NPI:1558739193
Name:POTTS, DANIELLE E (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:E
Last Name:POTTS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:E
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-0373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 S PENN AVE
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-1371
Practice Address - Country:US
Practice Address - Phone:304-643-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0144484Medicaid
OHP01696728OtherRAILROAD MEDICARE - MHCPI
OHP01696728OtherRAILROAD MEDICARE - MHCPI
OH0144484Medicaid