Provider Demographics
NPI:1508268442
Name:GREEN, KASEY CORY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:CORY
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 S TELEPHONE RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2968
Mailing Address - Country:US
Mailing Address - Phone:405-237-7507
Mailing Address - Fax:
Practice Address - Street 1:2900 S TELEPHONE RD
Practice Address - Street 2:SUITE 250
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2968
Practice Address - Country:US
Practice Address - Phone:405-237-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK87123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily