MEDICARE: MARK S GREEN PA

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	560	SC
2	363A00000X	Physician Assistant	002321	GA

General Provider Information

NPI Number	:	1396736336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK S GREEN PA

Provider Business Mailing Address
First Line	:	PO BOX 749306
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-9306
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1847 S LAKE DR
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-7759
Country	:	US
Telephone Number	:	803-356-8998
Fax Number	:

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	02/10/2025

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Directions to “ MARK S GREEN PA” Practice Location

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