Provider Demographics
NPI:1619979721
Name:GREEN, LINDA SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUE
Last Name: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 1:3515 MASSILLON RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-6400
Mailing Address - Country:US
Mailing Address - Phone:330-868-6044
Mailing Address - Fax:
Practice Address - Street 1:1028 E LINCOLNWAY
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-1216
Practice Address - Country:US
Practice Address - Phone:330-868-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGRPA11142Medicare ID - Type Unspecified