Provider Demographics
NPI:1083988323
Name:POULOS, KATHRYN MARIE
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:POULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9377 N HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4622
Mailing Address - Country:US
Mailing Address - Phone:734-451-0070
Mailing Address - Fax:734-451-1583
Practice Address - Street 1:9377 N HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170
Practice Address - Country:US
Practice Address - Phone:734-451-0070
Practice Address - Fax:734-451-1583
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006317OtherLICENSE