Healthcare Provider Details

I. General information

NPI: 1053873273
Provider Name (Legal Business Name): ELISSA CLAIR GREEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 CAROLINA ST STE 101
GREENSBORO NC
27401-6002
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-235-4372
  • Fax: 336-235-4381
Mailing address:
  • Phone: 336-716-1331
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08976
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: