Provider Demographics
NPI:1053919712
Name:GREEN, DANA FRANCES (PA-C)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:FRANCES
Last Name:GREEN
Suffix:
Gender:F
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 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-3468
Mailing Address - Fax:
Practice Address - Street 1:170 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-768-1270
Practice Address - Fax:336-794-3598
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10721363A00000X
363AM0700X
NC001010721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty