Amanda Boulos

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

12976 Issued in GA

Practice address

1371 Church Street Ext NE
Suite 200
Marietta, GA 30060-7913

Phone

(678) 481-0579

NPI assigned

Sep 15, 2023

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Advanced Urology Institute of GeorgiaGroup PAC ID 1759552607, 57 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Northside Hospital Cherokee Hospital, Canton, GA, CCN 110008

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Advanced Urology Institute of Georgia

  • Urology Physician
  • Snellville, GA
  • NPI 1073896510
  Medicare reassignment Care Compare group
• Advanced Urology Institute of Georgia PC

  • Urology Physician
  • Conyers, GA
  • NPI 1790411585
  NPD
• Advanced Urology Institute of Georgia, PC

  • Urology Physician
  • Dallas, GA
  • NPI 1811846348
  NPD
• Advanced Urology Institute of Georgia

  • Urology Physician
  • Roswell, GA
  • NPI 1386128494
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Northside Hospital, Inc.

  • General Acute Care Hospital
  • Canton, GA
  • NPI 1225050396
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1694736000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1745798400000",
    "number": "1194503722",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1551 JANMAR RD",
            "city": "SNELLVILLE",
            "state": "GA",
            "postal_code": "300785606",
            "telephone_number": "470-579-5600"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1371 CHURCH STREET EXT NE",
            "address_2": "SUITE 200",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300607913",
            "telephone_number": "678-481-0579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOULOS",
        "first_name": "AMANDA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2023-09-15",
        "last_updated": "2025-04-28",
        "certification_date": "2025-04-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "GA",
            "license": "12976",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Anna Swanson Bouchard, AGACNP-BC
• Lynette Boudreau, D.C.
• Tiffany Lee Boulanger, AGACNP
• Miriam Boulay, CRNA
• Karen E Boullain, RN
• Bounce, LLC
• Boundless Behavioral LLC
• Sydney L Bova, DC
• Althea M Bowe, OTR
• Ruth Chancey Bowen, EDS, LPC, NCC

• Surgical Physician Assistant in Marietta, GA
• Providers in Marietta, GA by specialty
• Surgical Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 28, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.