Provider Demographics
NPI:1376684100
Name:GREENE, LIZA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:M
Last Name:GREENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1310 WISCONSIN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2472
Mailing Address - Country:US
Mailing Address - Phone:616-844-4528
Mailing Address - Fax:
Practice Address - Street 1:1091 S BEACON BLVD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2607
Practice Address - Country:US
Practice Address - Phone:616-604-0096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-00802OtherSTATE LICENSE
MI5601007430OtherMI LICENSE