Healthcare Provider Details

I. General information

NPI: 1164850277
Provider Name (Legal Business Name): ALLYSON POTOCHNICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-4910
US

IV. Provider business mailing address

6 WILDFLOWER DR
WILKES BARRE PA
18702-7921
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6144
  • Fax:
Mailing address:
  • Phone: 570-808-8843
  • Fax: 570-808-8844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056406
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: