Provider Demographics
NPI:1215197058
Name:COUSOULAS, ARIADNE P (PA-C)
Entity Type:Individual
Prefix:
First Name:ARIADNE
Middle Name:P
Last Name:COUSOULAS
Suffix:
Gender:F
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 1:230 WEST PARKWAY
Mailing Address - Street 2:UNIT #10
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07440
Mailing Address - Country:US
Mailing Address - Phone:973-835-0800
Mailing Address - Fax:973-616-2766
Practice Address - Street 1:637 ROUTE 23 STE 300
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1419
Practice Address - Country:US
Practice Address - Phone:862-666-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00132000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0430595Medicaid