Provider Demographics
NPI:1851648448
Name:GREEN, AUTUMN-MARIE L (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:AUTUMN-MARIE
Middle Name:L
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 1:1100 W CENTRAL RD
Mailing Address - Street 2:#200
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005-2402
Mailing Address - Country:US
Mailing Address - Phone:847-392-5440
Mailing Address - Fax:
Practice Address - Street 1:1100 W CENTRAL RD
Practice Address - Street 2:#200
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-2402
Practice Address - Country:US
Practice Address - Phone:847-392-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant