Healthcare Provider Details

I. General information

NPI: 1821512500
Provider Name (Legal Business Name): CAMERON GREENE MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 NICOLET DR
GREEN BAY WI
54311-7003
US

IV. Provider business mailing address

2215 TRELLIS RIDGE LN APT 1
DE PERE WI
54115-4509
US

V. Phone/Fax

Practice location:
  • Phone: 920-465-2452
  • Fax:
Mailing address:
  • Phone: 920-860-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005992
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3031-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: