Provider Demographics
NPI:1255588828
Name:POTTER, SANDRA KAY (PA(ASCP))
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA(ASCP)
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:WYLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA(ASCP)
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:ST. JOHN'S HOSPITAL - DEPARTMENT OF PATHOLOGY
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-544-6464
Mailing Address - Fax:217-757-6032
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:ST. JOHN'S HOSPITAL - DEPARTMENT OF PATHOLOGY
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:217-757-6032
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical