Healthcare Provider Details

I. General information

NPI: 1477707800
Provider Name (Legal Business Name): ASHLEY MARIE POTTER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 AVONDALE HASLET RD STE 100
HASLET TX
76052
US

IV. Provider business mailing address

6161 N HWY 161 CREDENTIALING DEPARTMENT
IRVING TX
75038-2220
US

V. Phone/Fax

Practice location:
  • Phone: 817-766-4001
  • Fax: 817-766-4008
Mailing address:
  • Phone: 972-953-2439
  • Fax: 972-870-4915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11630
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: