Healthcare Provider Details

I. General information

NPI: 1013057801
Provider Name (Legal Business Name): LAURA ELIZABETH GREEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 SW 1ST AVE
OCALA FL
34471-6505
US

IV. Provider business mailing address

PO BOX 3130
OCALA FL
34478-3130
US

V. Phone/Fax

Practice location:
  • Phone: 352-867-8311
  • Fax: 352-867-1053
Mailing address:
  • Phone: 352-867-8311
  • Fax: 352-867-1053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9104085
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: