Provider Demographics
NPI:1508225640
Name:GREENE, ERIC JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOHN
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 1:138 MONTROSE AVE
Mailing Address - Street 2:UNIT 32
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1558
Mailing Address - Country:US
Mailing Address - Phone:610-525-2508
Mailing Address - Fax:
Practice Address - Street 1:138 MONTROSE AVE
Practice Address - Street 2:UNIT 32
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1558
Practice Address - Country:US
Practice Address - Phone:610-525-2508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical