Provider Demographics
NPI:1639746787
Name:POTTER, AARON RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:RYAN
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 1:3450 RIVERSTONE CT APT 1233
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0903
Mailing Address - Country:US
Mailing Address - Phone:208-932-3323
Mailing Address - Fax:
Practice Address - Street 1:3320 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4606
Practice Address - Country:US
Practice Address - Phone:208-656-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant