MEDICARE: MR. ROBERT 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	APA1526	OK

General Provider Information

NPI Number	:	1669424859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT GREEN PA

Provider Business Mailing Address
First Line	:	3501 NW 63RD ST
Second Line	:	SUITE 500
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-2237
Country	:	US
Telephone Number	:	405-842-4022
Fax Number	:	405-842-4024

Provider Business Practice Location Address
First Line	:	3501 NW 63RD ST
Second Line	:	SUITE 500
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-2237
Country	:	US
Telephone Number	:	405-842-4022
Fax Number	:	405-842-4024

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. ROBERT GREEN PA” Practice Location

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