Provider Demographics
NPI:1538503941
Name:BYNUM, INDIA GREEN (CRNA)
Entity Type:Individual
Prefix:
First Name:INDIA
Middle Name:GREEN
Last Name:BYNUM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:INDIA
Other - Middle Name:ALISA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2485 HEMBY LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3701
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:888-787-2249
Practice Address - Street 1:2485 HEMBY LN
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3701
Practice Address - Country:US
Practice Address - Phone:252-752-2140
Practice Address - Fax:888-787-2249
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC223297163W00000X
NC92654367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1538503941OtherTRICARE
NC1538503941Medicaid
NCQ43666AMedicare PIN