MEDICARE: JOHN GREEN RNFA

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	163WR0006X	Registered Nurse First Assistant	572015	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	572015	OTHER	TX	RN LICENSE

General Provider Information

NPI Number	:	1316133416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN GREEN RNFA

Provider Business Mailing Address
First Line	:	6724 CASTLE CREEK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3708
Country	:	US
Telephone Number	:	817-294-2087
Fax Number	:	817-656-3392

Provider Business Practice Location Address
First Line	:	6724 CASTLE CREEK DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3708
Country	:	US
Telephone Number	:	817-294-2087
Fax Number	:	817-656-3392

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

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	09/21/2007

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