Healthcare Provider Details

I. General information

NPI: 1962448480
Provider Name (Legal Business Name): CHANCE GREEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5448 HIGHWAY 260 STE 100
LAKESIDE AZ
85929-5736
US

IV. Provider business mailing address

135 N CENTER ST UNIT 5870
MESA AZ
85211-7159
US

V. Phone/Fax

Practice location:
  • Phone: 928-359-1862
  • Fax: 928-537-2049
Mailing address:
  • Phone: 480-874-7014
  • Fax: 480-874-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28162181
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: