Provider Demographics
NPI:1043284946
Name:GREEN, MARTHA R (MS PAS PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS PAS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 SPRINGVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8154
Mailing Address - Country:US
Mailing Address - Phone:843-832-5096
Mailing Address - Fax:843-572-7350
Practice Address - Street 1:75 SPRINGVIEW LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8154
Practice Address - Country:US
Practice Address - Phone:843-832-5096
Practice Address - Fax:843-832-5115
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC490207V00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ31626Medicare ID - Type Unspecified
SCQ31626Medicare UPIN