Provider Demographics
NPI:1790283067
Name:GREEN, SUSANNA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSANNA
Middle Name:LEIGH
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 1:16651 SOUTHWEST FWY STE 320
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2394
Mailing Address - Country:US
Mailing Address - Phone:346-874-2425
Mailing Address - Fax:
Practice Address - Street 1:16651 SOUTHWEST FWY STE 320
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2394
Practice Address - Country:US
Practice Address - Phone:346-874-2425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11514363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical