Provider Demographics
NPI:1427569045
Name:POULOS, ELIAS DEMETRIOS (PA-S)
Entity Type:Individual
Prefix:MR
First Name:ELIAS
Middle Name:DEMETRIOS
Last Name:POULOS
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:601 ROUTE 73 N STE 101
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3472
Practice Address - Country:US
Practice Address - Phone:856-237-8045
Practice Address - Fax:856-237-8047
Is Sole Proprietor?:No
Enumeration Date:2017-10-23
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00532700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant