Provider Demographics
NPI:1609892413
Name:POTTER, STEPHANIE KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:KATHRYN
Last Name:POTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MULLINS DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-3983
Mailing Address - Country:US
Mailing Address - Phone:541-259-0200
Mailing Address - Fax:
Practice Address - Street 1:302 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6039
Practice Address - Country:US
Practice Address - Phone:208-369-4590
Practice Address - Fax:208-906-2346
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR-0872207Q00000X
TXN-3251207Q00000X
IDM-10113207Q00000X
ORMD177584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1196215OtherMEDICARE PTAN
ID1609892413Medicaid
IDP01009617OtherMEDICARE RAILROAD
ID1609892413Medicaid