Provider Demographics
NPI:1699841122
Name:GREEN, PAUL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
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 1:2255 LEWISVILLE CLEMMONS RD STE E
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-7460
Mailing Address - Country:US
Mailing Address - Phone:336-766-0505
Mailing Address - Fax:336-766-0153
Practice Address - Street 1:2255 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:SUITE E
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-7463
Practice Address - Country:US
Practice Address - Phone:336-766-0505
Practice Address - Fax:336-766-0153
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical