Provider Demographics
NPI:1265802623
Name:GREENE, AUTUMN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:GREENE
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 1:44344 DEQUINDRE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1040
Mailing Address - Country:US
Mailing Address - Phone:586-323-1500
Mailing Address - Fax:586-323-1515
Practice Address - Street 1:44344 DEQUINDRE RD STE 260
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:586-323-1500
Practice Address - Fax:586-323-1515
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009956363A00000X
MI5601007483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant