Provider Demographics
NPI:1558877860
Name:GREENE, RUSTY JAMES (NP)
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:JAMES
Last Name:GREENE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W 168TH ST # 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3725
Mailing Address - Country:US
Mailing Address - Phone:212-305-8039
Mailing Address - Fax:212-305-1754
Practice Address - Street 1:180 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3722
Practice Address - Country:US
Practice Address - Phone:212-305-8039
Practice Address - Fax:212-305-1754
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-21
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308319363LG0600X
NYF308319-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology