Provider Demographics
NPI:1588069066
Name:GREEN, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
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 1:1188 YADKINVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2037
Mailing Address - Country:US
Mailing Address - Phone:336-713-0555
Mailing Address - Fax:
Practice Address - Street 1:2311 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8905
Practice Address - Country:US
Practice Address - Phone:336-713-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05441363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical