Provider Demographics
NPI:1144889502
Name:POULOS, HEATHER (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:2225 CIVIC CENTER DR STE 224
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6332
Mailing Address - Country:US
Mailing Address - Phone:702-214-5948
Mailing Address - Fax:702-214-9439
Practice Address - Street 1:2225 CIVIC CENTER DR STE 224
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6332
Practice Address - Country:US
Practice Address - Phone:702-214-5948
Practice Address - Fax:702-214-9439
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant