MEDICARE: HEATHER POULOS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2161	NV

General Provider Information

NPI Number	:	1144889502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER POULOS PA-C

Provider Business Mailing Address
First Line	:	3900 CAMBRIDGE ST STE 102
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7440
Country	:	US
Telephone Number	:	702-307-5414
Fax Number	:	702-307-5416

Provider Business Practice Location Address
First Line	:	2225 CIVIC CENTER DR STE 224
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-6332
Country	:	US
Telephone Number	:	702-214-5948
Fax Number	:	702-214-9439

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	09/16/2025

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Directions to “ HEATHER POULOS PA-C” Practice Location

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