Provider Demographics
NPI:1609841097
Name:POTTER, MELISSA J (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:J
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:WHITMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67 BELMONT ST
Practice Address - Street 2:WORCESTER
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2657
Practice Address - Country:US
Practice Address - Phone:508-334-0545
Practice Address - Fax:508-334-6515
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP230801Medicare PIN
MAQ31609Medicare UPIN