Provider Demographics
NPI:1467699025
Name:GREEN, INA (PAC)
Entity Type:Individual
Prefix:
First Name:INA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PAC
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 14587
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-0587
Mailing Address - Country:US
Mailing Address - Phone:405-600-9988
Mailing Address - Fax:405-600-9989
Practice Address - Street 1:4335 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:DEL CITY
Practice Address - State:OK
Practice Address - Zip Code:73115-3001
Practice Address - Country:US
Practice Address - Phone:405-600-9988
Practice Address - Fax:405-600-9989
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant