Provider Demographics
NPI:1740266113
Name:POTTER, DOREEN L (PA)
Entity type:Individual
Prefix:
First Name:DOREEN
Middle Name:L
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 304
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-0304
Mailing Address - Country:US
Mailing Address - Phone:518-692-9861
Mailing Address - Fax:518-692-7947
Practice Address - Street 1:1134 STATE ROUTE 29
Practice Address - Street 2:GREENWICH FAMILY HEALTH CENTER
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-6107
Practice Address - Country:US
Practice Address - Phone:518-692-9861
Practice Address - Fax:518-692-7947
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347400Medicaid
NYP00370312OtherRR MEDICARE
P34918Medicare UPIN
NYPA1602Medicare PIN