Provider Demographics
NPI:1275093320
Name:GREEN, STEPHAN A
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 S MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229 S MORRISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-5725
Practice Address - Country:US
Practice Address - Phone:920-832-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program