Provider Demographics
NPI:1285123919
Name:GREEN, CATHERINE LARSEN (PA)
Entity type:Individual
Prefix:MS
First Name:CATHERINE
Middle Name:LARSEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:MARY
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:227 RIVERSTONE DR STE D
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-720-7733
Mailing Address - Fax:
Practice Address - Street 1:227 RIVERSTONE DR STE D
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-720-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant