Provider Demographics
NPI:1316960404
Name:POTTS, KENNETH K (CRNA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:POTTS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 EAST 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:MENDOTA
Mailing Address - State:IL
Mailing Address - Zip Code:61342-9216
Mailing Address - Country:US
Mailing Address - Phone:815-539-7461
Mailing Address - Fax:815-539-1461
Practice Address - Street 1:1401 EAST 12TH STREET
Practice Address - Street 2:
Practice Address - City:MENDOTA
Practice Address - State:IL
Practice Address - Zip Code:61342-9216
Practice Address - Country:US
Practice Address - Phone:815-539-7461
Practice Address - Fax:815-539-1461
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041136641367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
L61377Medicare ID - Type Unspecified