Healthcare Provider Details

I. General information

NPI: 1336189547
Provider Name (Legal Business Name): DAVID E GREENE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 EAST BARNETTE RD
MEDFORD OR
97504-8332
US

IV. Provider business mailing address

PO BOX 4749
MEDFORD OR
97501-0227
US

V. Phone/Fax

Practice location:
  • Phone: 541-789-4673
  • Fax: 541-789-5678
Mailing address:
  • Phone: 541-789-4111
  • Fax: 541-789-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01120
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: