Provider Demographics
NPI:1821307752
Name:KOHLI, AMANDA ROUSLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROUSLIN
Last Name:KOHLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEANNE
Other - Last Name:ROUSLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1100 WALNUT ST STE 702
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5563
Mailing Address - Country:US
Mailing Address - Phone:215-955-2165
Mailing Address - Fax:215-923-7957
Practice Address - Street 1:1100 WALNUT ST STE 702
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5563
Practice Address - Country:US
Practice Address - Phone:215-955-2165
Practice Address - Fax:215-923-7957
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057526363A00000X, 363AS0400X
NY014268363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant