Basic Information
| Provider Information | |||||||||
| NPI: | 1265158281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | CORBETT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RRT/RCP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 CHUKKA HINA | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747017117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809202100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 CHUKKA HINA | ||||||||
| Address2: | |||||||||
| City: | DURANT | ||||||||
| State: | OK | ||||||||
| PostalCode: | 747017117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809202100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2022 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2279G1100X | 3048 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | General Care |
No ID Information.