Provider Demographics
NPI:1407082480
Name:GREEN, EDWARD CARL (CWOCN)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CARL
Last Name:GREEN
Suffix:
Gender:M
Credentials:CWOCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5004 FOOTHILLS RD
Mailing Address - Street 2:APT E
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-3156
Mailing Address - Country:US
Mailing Address - Phone:503-720-9891
Mailing Address - Fax:
Practice Address - Street 1:5004 FOOTHILLS RD
Practice Address - Street 2:APT E
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-3156
Practice Address - Country:US
Practice Address - Phone:503-720-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200542242RN163WW0000X
WARN 60087413163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care