Provider Demographics
NPI:1225028210
Name:GREEN, JONATHAN (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 LYNCH RD
Mailing Address - Street 2:STE 250
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-2998
Mailing Address - Country:US
Mailing Address - Phone:812-485-6940
Mailing Address - Fax:812-485-6949
Practice Address - Street 1:10444 SR 66 N
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-7954
Practice Address - Country:US
Practice Address - Phone:812-853-9651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000335A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS79193Medicare UPIN