Provider Demographics
NPI:1265576227
Name:POTTS, STEPHANIE EGLESTON (PA-C)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:EGLESTON
Last Name:POTTS
Suffix:
Gender:F
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 1:6 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:HOPE VALLEY
Mailing Address - State:RI
Mailing Address - Zip Code:02832-3417
Mailing Address - Country:US
Mailing Address - Phone:401-364-8786
Mailing Address - Fax:
Practice Address - Street 1:1111 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPE VALLEY
Practice Address - State:RI
Practice Address - Zip Code:02832-1610
Practice Address - Country:US
Practice Address - Phone:401-539-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00198363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI700867Medicaid
RI700867Medicaid