Provider Demographics
NPI:1346345865
Name:POULOS, VALERIE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:VALERIE
Middle Name:L
Last Name:POULOS
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 1:118 NORTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6009
Mailing Address - Country:US
Mailing Address - Phone:207-589-4509
Mailing Address - Fax:
Practice Address - Street 1:43 W MAIN ST
Practice Address - Street 2:DONALD WALKER HEALTH CENTER
Practice Address - City:LIBERTY
Practice Address - State:ME
Practice Address - Zip Code:04949-3400
Practice Address - Country:US
Practice Address - Phone:207-589-4509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-373363A00000X
MEPA142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEQX1101Medicare PIN