Provider Demographics
NPI:1356324537
Name:GREEN, TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:181 DANIEL RD
Practice Address - Street 2:STE A
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-7151
Practice Address - Country:US
Practice Address - Phone:828-287-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101971363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1356324537Medicaid
SC0172PAMedicaid
NC1356324537Medicaid
NCS97751Medicare UPIN
NCNC2938FMedicare PIN
NCNC2938DMedicare PIN
SC0172PAMedicaid
NCNC2938GMedicare PIN
NCNC2938CMedicare PIN
NC2752726BMedicare PIN