Healthcare Provider Details

I. General information

NPI: 1497086177
Provider Name (Legal Business Name): MR. GREGORY POTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD NAVAL HOSPITAL BMC MCAS
CAMP LEJEUNE NC
28542
US

IV. Provider business mailing address

45 HILAND SPRINGS WAY APT C
QUEENSBURY NY
12804-3115
US

V. Phone/Fax

Practice location:
  • Phone: 910-449-6500
  • Fax: 910-449-6532
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: