Provider Demographics
NPI:1447210117
Name:GREEN, JONATHAN MARTIN (PAC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MARTIN
Last Name:GREEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003263-L363A00000X
NY007516-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02104052Medicaid
NYC8362OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
PAGU039978OtherMEDICARE GROUP
NYP00331479OtherRR MEDICARE PIN
PA970015812OtherRR MEDICARE PIN
NYC8362OtherRR MEDICARE GROUP
PACC9269OtherRR MEDICARE GROUP
NY02104052Medicaid