Provider Demographics
NPI:1619332020
Name:POTTER, CHADLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:CHADLEY
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LANCASTER AVE # MSB275
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-572-0171
Mailing Address - Fax:
Practice Address - Street 1:100 E LANCASTER AVE # MSB275
Practice Address - Street 2:
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-572-0171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059118363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical