Basic Information
| Provider Information | |||||||||
| NPI: | 1255588828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA(ASCP) | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WYLIE | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA(ASCP) | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 800 E CARPENTER ST | ||||||||
| Address2: | ST. JOHN'S HOSPITAL - DEPARTMENT OF PATHOLOGY | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627690001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 2177576032 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E CARPENTER ST | ||||||||
| Address2: | ST. JOHN'S HOSPITAL - DEPARTMENT OF PATHOLOGY | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627690001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175446464 | ||||||||
| FaxNumber: | 2177576032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2008 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.