Provider Demographics
NPI:1417967340
Name:GREEN, ROBERT L JR (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 DALROCK RD
Mailing Address - Street 2:#1512
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4402
Mailing Address - Country:US
Mailing Address - Phone:915-872-0067
Mailing Address - Fax:
Practice Address - Street 1:1400 GEORGE DIETER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7601
Practice Address - Country:US
Practice Address - Phone:915-857-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9774OtherBC/BS OF TEXAS
TXP90589Medicare UPIN