Provider Demographics
NPI:1093891145
Name:GREEN, KRISTEN M (PA, RPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MARBLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHATEAUGAY
Mailing Address - State:NY
Mailing Address - Zip Code:12920-3600
Mailing Address - Country:US
Mailing Address - Phone:518-353-6120
Mailing Address - Fax:
Practice Address - Street 1:102 MARBLE RIVER RD
Practice Address - Street 2:
Practice Address - City:CHATEAUGAY
Practice Address - State:NY
Practice Address - Zip Code:12920-3600
Practice Address - Country:US
Practice Address - Phone:518-353-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007860-1174400000X, 2251P0200X
NY005277363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No174400000XOther Service ProvidersSpecialist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01154067Medicare ID - Type Unspecified