MEDICARE: RICHARD POTTER RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	97815	CO

General Provider Information

NPI Number	:	1912229295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD POTTER RNFA

Provider Business Mailing Address
First Line	:	PO BOX 76510
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80970-6510
Country	:	US
Telephone Number	:	719-638-8844
Fax Number	:	719-638-8115

Provider Business Practice Location Address
First Line	:	1322 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-3317
Country	:	US
Telephone Number	:	719-638-8844
Fax Number	:	719-638-8115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2010
Last Update Date	:	02/27/2010

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