Provider Demographics
NPI:1548592355
Name:GREEN, MEGAN B (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:B
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY STE 35
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3545
Mailing Address - Country:US
Mailing Address - Phone:806-761-0333
Mailing Address - Fax:806-785-7685
Practice Address - Street 1:6205 43RD ST # 100
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-3828
Practice Address - Country:US
Practice Address - Phone:806-749-2263
Practice Address - Fax:806-749-2264
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213074202Medicaid
TXTXB141446Medicare PIN