MEDICARE: JACQUELINE GREENE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	102661	NC

General Provider Information

NPI Number	:	1457333551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE GREENE PA-C

Provider Business Mailing Address
First Line	:	125 BALDWIN AVE
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-3227
Country	:	US
Telephone Number	:	704-384-9113
Fax Number	:	704-384-9118

Provider Business Practice Location Address
First Line	:	1401 MATTHEWS TOWNSHIP PKWY
Second Line	:	SUITE 200
City	:	MATTHEWS
State	:	NC
Zip	:	28105-5402
Country	:	US
Telephone Number	:	704-384-6901
Fax Number	:	704-384-6902

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	10/28/2020

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