Provider Demographics
NPI:1811213150
Name:POTTER, VANESSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:M
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:M
Other - Last Name:TIELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-778-5677
Mailing Address - Fax:402-778-5678
Practice Address - Street 1:2727 S 144TH ST STE 140
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5226
Practice Address - Country:US
Practice Address - Phone:402-778-5677
Practice Address - Fax:402-778-5678
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1490OtherNE STATE LICENSE