Basic Information
| Provider Information | |||||||||
| NPI: | 1194184424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTEET | ||||||||
| FirstName: | LORE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443642778 | ||||||||
| FaxNumber: | 2539856879 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443642778 | ||||||||
| FaxNumber: | 2539856879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2016 | ||||||||
| LastUpdateDate: | 02/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 43501 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP60759824 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2191131 | 05 | WA | MEDICAID | 154065300 | 05 | WY | MEDICAID |