Healthcare Provider Details

I. General information

NPI: 1407082480
Provider Name (Legal Business Name): EDWARD CARL GREEN CWOCN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 FOOTHILLS RD APT E
LAKE OSWEGO OR
97034-3156
US

IV. Provider business mailing address

5004 FOOTHILLS RD APT E
LAKE OSWEGO OR
97034-3156
US

V. Phone/Fax

Practice location:
  • Phone: 503-720-9891
  • Fax:
Mailing address:
  • Phone: 503-720-9891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number200542242RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN 60087413
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: