MEDICARE: MRS. TIARA DANTRELL GOOD-GREENE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-12698	NC

General Provider Information

NPI Number	:	1205552924
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIARA DANTRELL GOOD-GREENE PA-C

Provider Business Mailing Address
First Line	:	1120 EDGEBROOK DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-3308
Country	:	US
Telephone Number	:	864-466-2460
Fax Number	:

Provider Business Practice Location Address
First Line	:	3001 LYNDHURST AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4026
Country	:	US
Telephone Number	:	336-765-0383
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2022
Last Update Date	:	10/14/2022

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