Healthcare Provider Details

I. General information

NPI: 1174828867
Provider Name (Legal Business Name): COREY EDWARD GREENE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SHAE AVE STE A
CHAPMANVILLE WV
25508-9805
US

IV. Provider business mailing address

40 SHAE AVE STE A
CHAPMANVILLE WV
25508-9805
US

V. Phone/Fax

Practice location:
  • Phone: 304-310-2261
  • Fax: 304-310-2262
Mailing address:
  • Phone: 304-310-2261
  • Fax: 304-310-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number679
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number01532
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: