Provider Demographics
NPI:1861464075
Name:POTTER, JEREMY (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11277 VERNON PLACE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-3717
Mailing Address - Country:US
Mailing Address - Phone:814-724-1252
Mailing Address - Fax:814-333-8871
Practice Address - Street 1:11277 VERNON PLACE
Practice Address - Street 2:SUITE 200
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3717
Practice Address - Country:US
Practice Address - Phone:814-724-1252
Practice Address - Fax:814-333-8871
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051202207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP78944Medicare UPIN
PA089130EMHMedicare PIN