Basic Information
| Provider Information | |||||||||
| NPI: | 1558503409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1285 UPPER HEMBREE RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300761143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703438565 | ||||||||
| FaxNumber: | 7703438651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1285 UPPER HEMBREE RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300761143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703438565 | ||||||||
| FaxNumber: | 7703438651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1793 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 003119893F | 05 | GA | MEDICAID | 003119893G | 05 | GA | MEDICAID | 003119893J | 05 | GA | MEDICAID | 003119893E | 05 | GA | MEDICAID | 003119893K | 05 | GA | MEDICAID |