Provider Demographics
NPI:1518948769
Name:FLETCHER-GREEN, CARMELA (PA-C)
Entity Type:Individual
Prefix:
First Name:CARMELA
Middle Name:
Last Name:FLETCHER-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 1:1306 VERSAILLES RD STE 120
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1795
Mailing Address - Country:US
Mailing Address - Phone:859-259-2635
Mailing Address - Fax:592-547-8748
Practice Address - Street 1:1306 VERSAILLES RD STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1795
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA304363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY11478958OtherCAQH
KY95002937Medicaid
KY970021336OtherRAILROAD MEDICARE
KY7145Medicare PIN
KYP34554Medicare UPIN