Provider Demographics
NPI:1508377060
Name:POULOS, AMANDA SUE (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:POULOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:848-288-6935
Mailing Address - Fax:732-790-0107
Practice Address - Street 1:1412 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-2908
Practice Address - Country:US
Practice Address - Phone:215-235-9600
Practice Address - Fax:215-684-5360
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00931200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant