Provider Demographics
NPI:1548937162
Name:POUTROS, TERESA KAS (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:KAS
Last Name:POUTROS
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15506 CLAREMONT DR N
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3576
Mailing Address - Country:US
Mailing Address - Phone:586-567-5556
Mailing Address - Fax:
Practice Address - Street 1:25130 SOUTHFIELD RD STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1900
Practice Address - Country:US
Practice Address - Phone:248-234-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG05210095363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology