Provider Demographics
NPI:1356328231
Name:GREEN, ANDREA C (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:C
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 1:1 MEDICAL VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3403
Mailing Address - Country:US
Mailing Address - Phone:859-301-2000
Mailing Address - Fax:859-426-4140
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2000
Practice Address - Fax:859-426-4140
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH55001096363A00000X
IN10004353A363A00000X
KYPA900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95006151Medicaid
OH0077725Medicaid
KYK074310Medicare PIN
OH9261962Medicare UPIN
OH0077725Medicaid