Healthcare Provider Details

I. General information

NPI: 1144431800
Provider Name (Legal Business Name): PATRICK NELSON GREEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PAT GREEN M.D.

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W 1180 N SUITE # 5
TOOELE UT
84074
US

IV. Provider business mailing address

134 W 1180 N SUITE # 5
TOOELE UT
84074
US

V. Phone/Fax

Practice location:
  • Phone: 435-248-0333
  • Fax: 435-248-0334
Mailing address:
  • Phone: 435-248-0333
  • Fax: 435-248-0334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number6846499-8905
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6846499-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: