Provider Demographics
NPI:1992973044
Name:BOULIS, AMANDA E (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:BOULIS
Suffix:
Gender:F
Credentials:PA
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 84026
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-8426
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1600 E JEFFERSON ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5698
Practice Address - Country:US
Practice Address - Phone:206-320-7300
Practice Address - Fax:206-320-4698
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10362363A00000X
WATA10005363363A00000X
TXPA16207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant