Provider Demographics
NPI:1578180535
Name:POTLER-JACK, DEVON
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:POTLER-JACK
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 1:982 VIRGINIA AVE NE APT 2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3608
Mailing Address - Country:US
Mailing Address - Phone:678-994-6719
Mailing Address - Fax:
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-793-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant