Provider Demographics
NPI:1588386759
Name:GREENE, ADAM JONATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JONATHAN
Last Name:GREENE
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:130 STONECREST RD STE 106
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-8126
Practice Address - Country:US
Practice Address - Phone:502-647-7708
Practice Address - Fax:502-647-7747
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC308363A00000X
363A00000X
KYPA3082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300071350Medicaid
KY7100853770Medicaid