Provider Demographics
NPI:1699926519
Name:POTTER, SIMON (LAC)
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11745
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-5745
Mailing Address - Country:US
Mailing Address - Phone:206-214-7149
Mailing Address - Fax:
Practice Address - Street 1:187 PARFITT WAY SW
Practice Address - Street 2:SUITE G110
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2595
Practice Address - Country:US
Practice Address - Phone:206-214-7149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA00003031171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist