Provider Demographics
NPI:1285747378
Name:GREEN, JAMES EDWARD (AA, PA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDWARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:AA, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9493
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001816363A00000X
MI263367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00343185OtherRAILROAD MEDICARE PIN
MIM73860-008OtherMEDICARE
MI1598712390OtherGROUP NPI
MIM73860-008OtherMEDICARE
MI0M94800044Medicare PIN
MID16094145Medicare PIN