Provider Demographics
NPI:1760550800
Name:POTTANAT, JANCY G (MD)
Entity Type:Individual
Prefix:
First Name:JANCY
Middle Name:G
Last Name:POTTANAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 24TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801-1716
Mailing Address - Country:US
Mailing Address - Phone:804-734-9910
Mailing Address - Fax:804-734-9594
Practice Address - Street 1:700 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801-1716
Practice Address - Country:US
Practice Address - Phone:804-734-9910
Practice Address - Fax:804-734-9594
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101263501207Q00000X
IN01040779207QA0000X, 207QA0401X, 207QA0505X, 207QG0300X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100089630Medicaid
080091555OtherRAILROAD
KY64880123OtherKY MEDICAID
IN000000109476OtherANTHEM
IN849800FFMedicare PIN
080091555OtherRAILROAD
IN000000109476OtherANTHEM