Provider Demographics
NPI:1902369622
Name:POTTS, AMANDA (PA-C, MHS)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:POTTS
Suffix:
Gender:F
Credentials:PA-C, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2420
Mailing Address - Country:US
Mailing Address - Phone:203-314-4514
Mailing Address - Fax:
Practice Address - Street 1:1625 STRAITS TPKE STE 307
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1836
Practice Address - Country:US
Practice Address - Phone:203-758-8995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4411363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant