Provider Demographics
NPI:1619935335
Name:GREEN, CARL LEE (PA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:LEE
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 1:1015 N FIREFLY CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-9437
Mailing Address - Country:US
Mailing Address - Phone:316-721-5284
Mailing Address - Fax:
Practice Address - Street 1:750 W D AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1266
Practice Address - Country:US
Practice Address - Phone:620-532-3147
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS042639OtherBLUE CROSS/BLUE SHIELD
KS042639OtherBLUE CROSS/BLUE SHIELD
KSP35556Medicare UPIN