Healthcare Provider Details

I. General information

NPI: 1669434262
Provider Name (Legal Business Name): JULIE GREEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 5TH ST
BROOKINGS OR
97415-9702
US

IV. Provider business mailing address

500 5TH ST
BROOKINGS OR
97415-9702
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-2000
  • Fax: 541-412-2080
Mailing address:
  • Phone: 541-412-2000
  • Fax: 541-412-2080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA214203
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01034
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: