Healthcare Provider Details

I. General information

NPI: 1265576227
Provider Name (Legal Business Name): STEPHANIE EGLESTON POTTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MAIN ST
HOPE VALLEY RI
02832-1610
US

IV. Provider business mailing address

6 FAIRWAY DR
HOPE VALLEY RI
02832-3417
US

V. Phone/Fax

Practice location:
  • Phone: 401-539-0283
  • Fax:
Mailing address:
  • Phone: 401-364-8786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00198
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: