Provider Demographics
NPI:1346825338
Name:GREEN, REBECCA LAUREN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:LAUREN
Last Name:GREEN
Suffix:
Gender:F
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 1:10340 CITY CENTER BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4483
Mailing Address - Country:US
Mailing Address - Phone:561-215-0780
Mailing Address - Fax:
Practice Address - Street 1:5340 N FEDERAL HWY STE 110
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7058
Practice Address - Country:US
Practice Address - Phone:754-212-2935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical