Basic Information
| Provider Information | |||||||||
| NPI: | 1871694166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTER | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6555 COYLE AVE | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956080302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165362500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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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 | 207Q00000X | PA10542 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 461157 | 01 | CA | INTERPLAN | OTHER | 5187068 | 01 | CA | AETNA | OTHER | PA10542 | 01 | CA | BLUE CROSS | OTHER | 1750460 | 01 | CA | GREAT WEST | OTHER | 2689218 | 01 | CA | UNITED HEALTHCARE | OTHER | 7251591 | 01 | CA | CIGNA | OTHER | 90098209 | 01 | CA | PACIFICARE | OTHER |