Basic Information
| Provider Information | |||||||||
| NPI: | 1710297312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | WILKS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NEERING | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | WILKS | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17197 N LAUREL PARK DR | ||||||||
| Address2: | SUITE 161 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343388300 | ||||||||
| FaxNumber: | 7343388301 | ||||||||
| Practice Location | |||||||||
| Address1: | 17197 N LAUREL PARK DR | ||||||||
| Address2: | SUITE 161 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343388300 | ||||||||
| FaxNumber: | 7343388301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2010 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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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 | 363A00000X | 2497 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601006325 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 700H231390 | 01 | MI | BCBS GROUP NUMBER | OTHER |