Healthcare Provider Details

I. General information

NPI: 1245467828
Provider Name (Legal Business Name): TONY RAY POTTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date: 10/05/2015
Reactivation Date: 10/03/2019

III. Provider practice location address

8402 CLAY ST
WESTMINSTER CO
80031-3810
US

IV. Provider business mailing address

8402 CLAY ST
WESTMINSTER CO
80031-3810
US

V. Phone/Fax

Practice location:
  • Phone: 303-487-7775
  • Fax:
Mailing address:
  • Phone: 303-487-7775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009212
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112295
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: