Basic Information
| Provider Information | |||||||||
| NPI: | 1215549456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 CINEMA DR UNIT 22 | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859532445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 740 S MEADOW ST | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148505377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6073194563 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2020 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 025510 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.