Provider Demographics
NPI:1053521302
Name:GREEN, KEVIN JOSEPH (PA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:GREEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ALVIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-1833
Mailing Address - Country:US
Mailing Address - Phone:814-266-1544
Mailing Address - Fax:814-266-0177
Practice Address - Street 1:1450 SCALP AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3374
Practice Address - Country:US
Practice Address - Phone:814-266-8466
Practice Address - Fax:814-266-0177
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002387-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA130273Medicare PIN