Provider Demographics
NPI:1164041034
Name:GREEN, SHEA ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:ELIZABETH
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 E DESERT COVE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6280
Mailing Address - Country:US
Mailing Address - Phone:480-273-8510
Mailing Address - Fax:480-214-9933
Practice Address - Street 1:8752 E VIA DE COMMERCIO STE 1
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-3396
Practice Address - Country:US
Practice Address - Phone:480-684-1080
Practice Address - Fax:480-684-1081
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ085142Medicaid
AZ085142Medicaid