Healthcare Provider Details

I. General information

NPI: 1003881020
Provider Name (Legal Business Name): JAMES POTOCSNAK PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 RUCKER AVE
EVERETT WA
98201
US

IV. Provider business mailing address

2320 RUCKER AVE
EVERETT WA
98201
US

V. Phone/Fax

Practice location:
  • Phone: 425-259-5121
  • Fax: 425-252-1322
Mailing address:
  • Phone: 425-259-5121
  • Fax: 425-252-1322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10001718
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: