Healthcare Provider Details

I. General information

NPI: 1134693518
Provider Name (Legal Business Name): TRAVIS RAY GREEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-4574
  • Fax:
Mailing address:
  • Phone: 952-767-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12938
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: