Provider Demographics
NPI:1245467828
Name:POTTER, TONY RAY (PA-C)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:RAY
Last Name:POTTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3184
Mailing Address - Country:US
Mailing Address - Phone:321-722-5200
Mailing Address - Fax:
Practice Address - Street 1:400 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3184
Practice Address - Country:US
Practice Address - Phone:321-722-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2019-10-03
Deactivation Date:2015-10-05
Deactivation Code:
Reactivation Date:2019-10-03
Provider Licenses
StateLicense IDTaxonomies
FLPA9112295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant