Provider Demographics
NPI:1275529158
Name:GREEN, JAMES MILTON (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MILTON
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SHERIDAN RD
Mailing Address - Street 2:#109
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2701
Mailing Address - Country:US
Mailing Address - Phone:360-377-3395
Mailing Address - Fax:360-792-1249
Practice Address - Street 1:900 SHERIDAN RD
Practice Address - Street 2:#109
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2701
Practice Address - Country:US
Practice Address - Phone:360-377-3395
Practice Address - Fax:360-792-1249
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8141202Medicaid
WAG8854055Medicare PIN