Provider Demographics
NPI:1396976155
Name:POTTER, RYAN (AUD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2707
Mailing Address - Country:US
Mailing Address - Phone:315-428-0016
Mailing Address - Fax:315-478-3913
Practice Address - Street 1:1001 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2707
Practice Address - Country:US
Practice Address - Phone:315-428-0016
Practice Address - Fax:315-478-3913
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002224231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist