Provider Demographics
NPI:1639833569
Name:GREEN, KATHRYN (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COMMONS BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-3821
Mailing Address - Country:US
Mailing Address - Phone:937-429-0607
Mailing Address - Fax:937-702-9041
Practice Address - Street 1:2510 COMMONS BLVD STE 210
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3821
Practice Address - Country:US
Practice Address - Phone:937-429-0607
Practice Address - Fax:937-702-9041
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007245RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical