Provider Demographics
NPI:1710072251
Name:GREEN, HOLLY (PA)
Entity Type:Individual
Prefix:MS
First Name:HOLLY
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 1:3701 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2804
Mailing Address - Country:US
Mailing Address - Phone:323-361-2331
Mailing Address - Fax:323-361-8491
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2154
Practice Address - Fax:323-361-3632
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N4760OtherBLUE CROSS BLUE SHIELD
TX180775202Medicaid
TXQ10279Medicare UPIN
TX8N4760OtherBLUE CROSS BLUE SHIELD