Provider Demographics
NPI:1073521738
Name:GREEN, RUTH ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:ANN
Other - Last Name:NEUBERGER, GARAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:
Practice Address - Street 1:4440 S WASHINGTON ST. - ALTRU PROFESSIONAL CENTER
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-7245
Practice Address - Country:US
Practice Address - Phone:701-732-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00577363A00000X
NDPAC0786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100402360BMedicaid
KS426761OtherBC/BS
KSS70079Medicare UPIN