Provider Demographics
NPI:1891787131
Name:POTRATZ, LEE RICHARD (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:RICHARD
Last Name:POTRATZ
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5112
Mailing Address - Country:US
Mailing Address - Phone:218-333-5171
Mailing Address - Fax:
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-751-9746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14022255A2300X
MN10848363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant