Healthcare Provider Details

I. General information

NPI: 1497836662
Provider Name (Legal Business Name): TERESA L. GREEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA L TROUP PA

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SIVLEY RD SW
HUNTSVILLE AL
35801-4421
US

IV. Provider business mailing address

930 FRANKLIN ST SE
HUNTSVILLE AL
35801-4312
US

V. Phone/Fax

Practice location:
  • Phone: 256-533-8362
  • Fax: 256-533-8262
Mailing address:
  • Phone: 256-519-8104
  • Fax: 256-519-8327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-108
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: