Healthcare Provider Details

I. General information

NPI: 1114966462
Provider Name (Legal Business Name): JUSTIN GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD STE A
LOS ALAMOS NM
87544-2292
US

IV. Provider business mailing address

3917 WEST RD
LOS ALAMOS NM
87544-2275
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-8900
  • Fax:
Mailing address:
  • Phone: 505-661-8900
  • Fax: 505-661-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4568
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: