Provider Demographics
NPI:1851746820
Name:POTVIN, RYAN (MACOM, EAMP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:POTVIN
Suffix:
Gender:M
Credentials:MACOM, EAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3923
Mailing Address - Country:US
Mailing Address - Phone:516-410-4216
Mailing Address - Fax:
Practice Address - Street 1:822 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98125-3923
Practice Address - Country:US
Practice Address - Phone:516-410-4216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60625379171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist