Provider Demographics
NPI:1225831159
Name:POTTER, WAGNER ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:WAGNER ANTONIO
Middle Name:
Last Name:POTTER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RUA SAPE 1020
Mailing Address - Street 2:APT 502
Mailing Address - City:PORTO ALEGRE
Mailing Address - State:RIO GRANDE DO SUL
Mailing Address - Zip Code:91350050
Mailing Address - Country:BR
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-5976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program