Provider Demographics
NPI:1326431644
Name:GREEN, JUSTIN (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-1540
Mailing Address - Fax:910-431-4048
Practice Address - Street 1:5211 COLLEGE RD S
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2209
Practice Address - Country:US
Practice Address - Phone:910-815-3170
Practice Address - Fax:910-793-5639
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-05606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant