Healthcare Provider Details

I. General information

NPI: 1962401455
Provider Name (Legal Business Name): IRA B POTTER PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MILLARD ALLEN DR.
LACKEY KY
41643-0190
US

IV. Provider business mailing address

PO BOX 190 77 MILLARD ALLEN DRIVE
LACKEY KY
41643-0190
US

V. Phone/Fax

Practice location:
  • Phone: 606-358-2381
  • Fax: 606-358-2404
Mailing address:
  • Phone: 606-358-2381
  • Fax: 606-358-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1587
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IRA BLAINE POTTER
Title or Position: PRESIDENT
Credential: MD
Phone: 606-358-2381