Provider Demographics
NPI:1114533072
Name:GREEN, GENEVA ANN (PA)
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5535 SW CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7151
Mailing Address - Country:US
Mailing Address - Phone:503-715-7864
Mailing Address - Fax:
Practice Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 130
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7737
Practice Address - Country:US
Practice Address - Phone:503-603-9087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant