Healthcare Provider Details

I. General information

NPI: 1457703548
Provider Name (Legal Business Name): CASEY NICHOLE GREEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASEY NICHOLE SHERMAN PA-C

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 BUSINESS PARK DR
TRAVERSE CITY MI
49686-8372
US

IV. Provider business mailing address

1023 BUSINESS PARK DR
TRAVERSE CITY MI
49686-8372
US

V. Phone/Fax

Practice location:
  • Phone: 231-389-6982
  • Fax: 231-216-7648
Mailing address:
  • Phone: 231-389-6982
  • Fax: 231-216-7648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007872
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: