Provider Demographics
NPI:1174828867
Name:GREENE, COREY EDWARD (PAC)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:EDWARD
Last Name:GREENE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 SHAE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CHAPMANVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25508-9805
Mailing Address - Country:US
Mailing Address - Phone:304-310-2261
Mailing Address - Fax:304-310-2262
Practice Address - Street 1:40 SHAE AVE STE A
Practice Address - Street 2:
Practice Address - City:CHAPMANVILLE
Practice Address - State:WV
Practice Address - Zip Code:25508-9805
Practice Address - Country:US
Practice Address - Phone:304-310-2261
Practice Address - Fax:304-310-2262
Is Sole Proprietor?:No
Enumeration Date:2011-01-11
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01532363AM0700X
WV679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810020048Medicaid
WV1174828867Medicaid
WVWV5447AMedicare PIN
WV2034892Medicare PIN
WV2034893Medicare PIN
WV2034891Medicare PIN
WV2034894Medicare PIN
WV1174828867Medicaid