Provider Demographics
NPI:1417956574
Name:GREEN, JEFFREY TRAVIS JR (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:TRAVIS
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78405-1807
Mailing Address - Country:US
Mailing Address - Phone:361-888-6782
Mailing Address - Fax:361-888-6788
Practice Address - Street 1:2502 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405-1807
Practice Address - Country:US
Practice Address - Phone:361-888-6782
Practice Address - Fax:361-888-6788
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02106363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR91524Medicare UPIN