Provider Demographics
NPI:1821557943
Name:POTTS, TREVOR ROCKWELL
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:ROCKWELL
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13165 BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8523
Mailing Address - Country:US
Mailing Address - Phone:605-490-1123
Mailing Address - Fax:
Practice Address - Street 1:216 ANAMARIA DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7366
Practice Address - Country:US
Practice Address - Phone:605-721-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCR001009367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered