Provider Demographics
NPI:1134198419
Name:GREEN, JARED A (PA-C)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:A
Last Name:GREEN
Suffix:
Gender:
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 1:1055 NORTH 500 WEST ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1870 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-7742
Practice Address - Country:US
Practice Address - Phone:435-383-9009
Practice Address - Fax:435-383-9010
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8441754-1206363A00000X, 363A00000X
AZ3301363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ067405Medicaid
Q56273Medicare UPIN
AZ067405Medicaid