Provider Demographics
NPI:1710297312
Name:POTTER, CARLA WILKS (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:WILKS
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:WILKS
Other - Last Name:NEERING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17197 N LAUREL PARK DR
Mailing Address - Street 2:SUITE 161
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2680
Mailing Address - Country:US
Mailing Address - Phone:734-338-8300
Mailing Address - Fax:734-338-8301
Practice Address - Street 1:17197 N LAUREL PARK DR
Practice Address - Street 2:SUITE 161
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2680
Practice Address - Country:US
Practice Address - Phone:734-338-8300
Practice Address - Fax:734-338-8301
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2497363A00000X
MI5601006325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H231390OtherBCBS GROUP NUMBER
MI0P47270Medicare PIN