Provider Demographics
NPI:1467528588
Name:GREENE, DOUGLAS ALLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALLAN
Last Name:GREENE
Suffix:
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:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:214 W 1500 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7408
Practice Address - Country:US
Practice Address - Phone:801-295-6483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT353133-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant