Provider Demographics
NPI:1407219686
Name:GREEN, ANDREW FAY
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:FAY
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 1:9000 S 31ST ST E
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-9001
Mailing Address - Country:US
Mailing Address - Phone:870-514-1978
Mailing Address - Fax:
Practice Address - Street 1:9000 S 31ST ST E
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-9001
Practice Address - Country:US
Practice Address - Phone:870-514-1978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator