Healthcare Provider Details

I. General information

NPI: 1245279405
Provider Name (Legal Business Name): TANYA RENITA GREEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRIS RD
HARRIS NY
12742-5030
US

IV. Provider business mailing address

403 E 1ST ST
DIXON IL
61021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-3300
  • Fax: 845-794-3240
Mailing address:
  • Phone: 815-288-5531
  • Fax: 815-285-5558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA06905
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002921
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: