Provider Demographics
NPI:1326548603
Name:GREEN, ANTHONY DARIUS (PTA)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DARIUS
Last Name:GREEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12645 ELVENKING LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-3481
Mailing Address - Country:US
Mailing Address - Phone:904-508-6213
Mailing Address - Fax:
Practice Address - Street 1:6248 103RD ST STE 105
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7733
Practice Address - Country:US
Practice Address - Phone:904-573-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant