Provider Demographics
NPI:1871694166
Name:POTTER, SUSAN B (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7115 GREENBACK LN
Practice Address - Street 2:FL 3
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-6133
Practice Address - Country:US
Practice Address - Phone:916-536-3540
Practice Address - Fax:916-536-2455
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA461157OtherINTERPLAN
CA5187068OtherAETNA
CAPA10542OtherBLUE CROSS
CA1750460OtherGREAT WEST
CA2689218OtherUNITED HEALTHCARE
CA7251591OtherCIGNA
CA90098209OtherPACIFICARE
CA5187068OtherAETNA
CA2689218OtherUNITED HEALTHCARE