Provider Demographics
NPI:1184604530
Name:GREEN, TROY A (PAC)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5629 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1952
Mailing Address - Country:US
Mailing Address - Phone:269-372-5701
Mailing Address - Fax:269-372-5702
Practice Address - Street 1:5629 STADIUM DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1952
Practice Address - Country:US
Practice Address - Phone:269-372-5701
Practice Address - Fax:269-372-5702
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C910950OtherBCBSM
MI1184604530Medicaid
MI700C910950OtherBCBSM