Healthcare Provider Details

I. General information

NPI: 1831133826
Provider Name (Legal Business Name): SEAN MICHAEL GREENE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 NW SPRUCE AVE
CORVALLIS OR
97330-2111
US

IV. Provider business mailing address

981 NW SPRUCE AVE
CORVALLIS OR
97330-2111
US

V. Phone/Fax

Practice location:
  • Phone: 541-758-0766
  • Fax: 541-753-2737
Mailing address:
  • Phone: 541-758-0766
  • Fax: 541-753-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00664
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: