Provider Demographics
NPI:1457333551
Name:GREENE, JACQUELINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:GREENE
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 1:125 BALDWIN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3227
Mailing Address - Country:US
Mailing Address - Phone:704-384-9113
Mailing Address - Fax:704-384-9118
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5402
Practice Address - Country:US
Practice Address - Phone:704-384-6901
Practice Address - Fax:704-384-6902
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752765Medicare ID - Type Unspecified
NCR66380Medicare UPIN