Provider Demographics
NPI:1730257981
Name:GREEN, MICHAEL ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
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 1:1500 SE MAGNOLIA EXT STE 203
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-4461
Mailing Address - Country:US
Mailing Address - Phone:352-629-1378
Mailing Address - Fax:352-629-1406
Practice Address - Street 1:1720 SE 16TH AVE STE 303
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-4620
Practice Address - Country:US
Practice Address - Phone:352-369-0288
Practice Address - Fax:352-867-1053
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109683363A00000X
FLPA 9103519363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1730257981OtherBLUE CROSS BLUE SHIELD
TX1730257981OtherBLUE CROSS BLUE SHIELD