Provider Demographics
NPI:1255610168
Name:POTTER, CLINTON WAYNE (PA-C)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:WAYNE
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 1:2257 NORTH OAK HALLOW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040
Mailing Address - Country:US
Mailing Address - Phone:801-660-7917
Mailing Address - Fax:
Practice Address - Street 1:144 S 500 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1907
Practice Address - Country:US
Practice Address - Phone:801-463-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1098530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant