Provider Demographics
NPI:1073859401
Name:GREEN, KRISTIAN ASHLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:ASHLEY
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735263
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5263
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1550 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7876
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7498
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004557363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP01188030OtherRAILROAD MEDICARE