Provider Demographics
NPI:1366786675
Name:POTOCHNIK, DAVID A (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:POTOCHNIK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 N SEMORAN BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-3800
Mailing Address - Country:US
Mailing Address - Phone:407-680-2273
Mailing Address - Fax:321-274-0224
Practice Address - Street 1:483 N SEMORAN BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-3800
Practice Address - Country:US
Practice Address - Phone:407-680-2273
Practice Address - Fax:321-274-0224
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106970363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGW488ZMedicare UPIN