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NPI Code Detail

MEDICARE: MR. LEE RICHARD POTRATZ PA-C, ATC

MEDICARE: MR. LEE RICHARD POTRATZ PA-C, ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer1402MN
2363A00000XPhysician Assistant10848MN
3363AS0400XSurgical Physician Assistant10848MN

General Provider Information

NPI Number : 1891787131
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LEE RICHARD POTRATZ PA-C, ATC
Provider Business Mailing Address
First Line : 1233 34TH ST NW
Second Line :
City : BEMIDJI
State : MN
Zip : 56601-5112
Country : US
Telephone Number : 218-333-5171
Fax Number :
Provider Business Practice Location Address
First Line : 1300 ANNE ST NW
Second Line :
City : BEMIDJI
State : MN
Zip : 56601-5103
Country : US
Telephone Number : 218-751-9746
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/22/2005
Last Update Date : 10/04/2019

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