Healthcare Provider Details

I. General information

NPI: 1730189861
Provider Name (Legal Business Name): CHERYL R GREEN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 11/27/2023
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HERITAGE WAY SUITE 2100
KALISPELL MT
59901-3158
US

IV. Provider business mailing address

350 HERITAGE WAY SUITE 2100
KALISPELL MT
59901-3158
US

V. Phone/Fax

Practice location:
  • Phone: 406-257-8992
  • Fax: 406-257-8996
Mailing address:
  • Phone: 406-257-8992
  • Fax: 406-257-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberAPA1318
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number40815
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: