Provider Demographics
NPI:1134895394
Name:GREEN, CASEY (PA-C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1533
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1533
Mailing Address - Country:US
Mailing Address - Phone:870-932-1820
Mailing Address - Fax:870-972-6712
Practice Address - Street 1:1010 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3503
Practice Address - Country:US
Practice Address - Phone:870-932-1820
Practice Address - Fax:870-972-6712
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty