Provider Demographics
NPI:1932129210
Name:GREEN, KATHLEEN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
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 1:227 ADAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01267-2932
Mailing Address - Country:US
Mailing Address - Phone:413-458-0112
Mailing Address - Fax:413-458-5114
Practice Address - Street 1:227 ADAMS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:MA
Practice Address - Zip Code:01267-2932
Practice Address - Country:US
Practice Address - Phone:413-458-0112
Practice Address - Fax:413-458-5114
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1737363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GR AP2099Medicare ID - Type Unspecified
S61684Medicare UPIN