Healthcare Provider Details

I. General information

NPI: 1871474106
Provider Name (Legal Business Name): THAXAL CREED POTTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S 2ND ST
MCALESTER OK
74501-5814
US

IV. Provider business mailing address

604 S 2ND ST
MCALESTER OK
74501-5814
US

V. Phone/Fax

Practice location:
  • Phone: 918-302-0052
  • Fax:
Mailing address:
  • Phone: 918-302-0052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: