Provider Demographics
NPI:1700022613
Name:GREEN, AMBRE JAMARRA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBRE
Middle Name:JAMARRA
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 1:218 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-1251
Mailing Address - Country:US
Mailing Address - Phone:941-961-3303
Mailing Address - Fax:
Practice Address - Street 1:218 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1251
Practice Address - Country:US
Practice Address - Phone:941-961-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106967363A00000X
GA005491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant