Provider Demographics
NPI:1669470845
Name:POTTER, JAMES G (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
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:ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Mailing Address - Street 2:400 EAST THIRD STREET
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-1183
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVENUE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5335
Practice Address - Country:US
Practice Address - Phone:715-817-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3621-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42908100Medicaid
1018475OtherPREFERREDONE
036Medicare PIN
1018475OtherPREFERREDONE
S07735Medicare UPIN