Provider Demographics
NPI:1669716528
Name:POTHIER, LAUREN M (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:POTHIER
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 1:75 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8960
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-8960
Practice Address - Country:US
Practice Address - Phone:765-778-0913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001456A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01347735OtherMEDICARE RR PTAN
INP01347735OtherMEDICARE RR PTAN