Provider Demographics
NPI:1013535582
Name:GREEN, PAUL MICHAEL (NP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD STE 230
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1252
Practice Address - Country:US
Practice Address - Phone:317-962-5820
Practice Address - Fax:317-962-3916
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71010148A363L00000X
IN28139746A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner