Provider Demographics
NPI:1265013841
Name:GREENE, KATELYN JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:JOY
Last Name:GREENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-2819
Mailing Address - Country:US
Mailing Address - Phone:903-240-3325
Mailing Address - Fax:
Practice Address - Street 1:1451 W AIRPORT FWY STE 1
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-6223
Practice Address - Country:US
Practice Address - Phone:469-931-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant