Healthcare Provider Details

I. General information

NPI: 1649624040
Provider Name (Legal Business Name): RICHARD GREEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 SHAW AVE STE 101
CLOVIS CA
93611-4096
US

IV. Provider business mailing address

1555 SHAW AVE STE 101
CLOVIS CA
93611-4096
US

V. Phone/Fax

Practice location:
  • Phone: 559-324-7001
  • Fax:
Mailing address:
  • Phone: 559-324-7001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53321
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: