Provider Demographics
NPI:1679592315
Name:POULIN, AMANDA D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:D
Last Name:POULIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:D
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:275 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-7217
Mailing Address - Country:US
Mailing Address - Phone:252-752-5077
Mailing Address - Fax:
Practice Address - Street 1:275 BETHESDA DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7217
Practice Address - Country:US
Practice Address - Phone:252-752-5077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004518363A00000X
VA0110002055363A00000X
NC0010-03544363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
009818M60Medicare ID - Type Unspecified
Q015551Medicare UPIN