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General NPI Number Information
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NPI Number | 1447837828
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Entity Type | Individual
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Provider Name | BROOKLYN WALSH GREEN PA-C
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Gender | Female
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Dates
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Enumeration Date | 03/24/2021
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Last Update Date | 04/20/2024
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Provider Practice Location Address
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Address Line | 100 MIMOSA DR FL 2
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City | THOMASVILLE
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State | GA
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Zip | 31792-6676
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Country | US
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Telephone | 229-228-5500
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Fax | 229-584-5985
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Provider Business Mailing Address
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Address Line | 100 MIMOSA DR FL 2
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City | THOMASVILLE
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State | GA
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Zip | 31792-6676
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Country | US
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Telephone | 229-228-5500
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Fax | 229-584-5985
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9114960
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 12179
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License Number State | GA
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