Provider Demographics
NPI:1861559387
Name:POTTS, JASON R (CRNP)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:R
Last Name:POTTS
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1337 BLUE VALLEY DR
Practice Address - Street 2:STE 8
Practice Address - City:PEN ARGYL
Practice Address - State:PA
Practice Address - Zip Code:18072-1815
Practice Address - Country:US
Practice Address - Phone:610-654-1230
Practice Address - Fax:610-654-1232
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA119817XRUMedicare PIN
PA119817XRNMedicare PIN