Provider Demographics
NPI:1447796875
Name:GREEN, ERIC (APRN)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-1448
Mailing Address - Country:US
Mailing Address - Phone:870-838-7300
Mailing Address - Fax:
Practice Address - Street 1:225 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3111
Practice Address - Country:US
Practice Address - Phone:870-207-1630
Practice Address - Fax:870-207-6581
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004965363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner