Basic Information
| Provider Information | |||||||||
| NPI: | 1255610168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | CLINTON | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 NORTH OAK HALLOW DRIVE | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016607917 | ||||||||
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| Practice Location | |||||||||
| Address1: | 144 S 500 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1098530 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.