Healthcare Provider Details

I. General information

NPI: 1093130783
Provider Name (Legal Business Name): CHADE B GREEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 RIVERSIDE PLAZA LN NW STE 100
ALBUQUERQUE NM
87120-2682
US

IV. Provider business mailing address

1600 NORTH MAIN
LOVINGTON NM
88260-2830
US

V. Phone/Fax

Practice location:
  • Phone: 505-322-6687
  • Fax:
Mailing address:
  • Phone: 575-396-6611
  • Fax: 575-396-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2014-0082
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5647
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5647
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: