Doctor Name: | JANIEL J GREEN |
NPI Number: | 1114297660 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PA-C |
License Number: | PA-957 |
Business Practice Address: | 36 Professional Plz Suite #102 Rexburg, ID - 834402049 |
Business Phone Number: | 2083560234 |
Business Fax Number: | 2086568444 |
Mailing Address: | 36 Professional Plz, Suite #102 REXBURG |
State: | ID |
Postal Code: | 834402049 |
Phone Number: | 2083560234 |
Fax Number: | 2086568444 |
NPI Enumeration Date: | 12/30/2011 |
NPI Last Update Date: | 12/30/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | PA-957 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |