MEDICARE: MR. EDWARD CARL GREEN CWOCN

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	163WW0000X	Wound Care Registered Nurse	200542242RN	OR
2	163WW0000X	Wound Care Registered Nurse	RN 60087413	WA

General Provider Information

NPI Number	:	1407082480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDWARD CARL GREEN CWOCN

Provider Business Mailing Address
First Line	:	5004 FOOTHILLS RD
Second Line	:	APT E
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3156
Country	:	US
Telephone Number	:	503-720-9891
Fax Number	:

Provider Business Practice Location Address
First Line	:	5004 FOOTHILLS RD
Second Line	:	APT E
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3156
Country	:	US
Telephone Number	:	503-720-9891
Fax Number	:

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

Provider Enumeration Date	:	06/04/2009
Last Update Date	:	06/04/2009

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