Basic Information
| Provider Information | |||||||||
| NPI: | 1467419853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POTTS | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11781 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5717775164 | ||||||||
| FaxNumber: | 7038902650 | ||||||||
| Practice Location | |||||||||
| Address1: | 7959 BUSTLETON AVENUE | ||||||||
| Address2: | AMERICAN ACCESS CARE OF PENNSYLVANIA, LLC | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157425662 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN689822 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 104397620 | 05 | MI | MEDICAID | P00029037 | 01 | MI | RAILROAD MEDICARE | OTHER |