Provider Demographics
NPI:1710980487
Name:POTTER, GREGG WESLEY (PT, MPT)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:WESLEY
Last Name:POTTER
Suffix:
Gender:M
Credentials:PT, MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1515
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-1515
Mailing Address - Country:US
Mailing Address - Phone:623-363-8691
Mailing Address - Fax:928-212-8727
Practice Address - Street 1:34301 S OLD BLACK CANYON HWY STE 7
Practice Address - Street 2:
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324-9728
Practice Address - Country:US
Practice Address - Phone:623-363-8691
Practice Address - Fax:928-212-8727
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3297225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ331041Medicaid