Healthcare Provider Details

I. General information

NPI: 1891787131
Provider Name (Legal Business Name): LEE RICHARD POTRATZ PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

1233 34TH ST NW
BEMIDJI MN
56601-5112
US

V. Phone/Fax

Practice location:
  • Phone: 218-751-9746
  • Fax:
Mailing address:
  • Phone: 218-333-5171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1402
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10848
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10848
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: