Provider Demographics
NPI:1568114734
Name:GREENE, GABRIEL GUSTAVO I (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:GUSTAVO
Last Name:GREENE
Suffix:I
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 207830
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7830
Mailing Address - Country:US
Mailing Address - Phone:888-412-2649
Mailing Address - Fax:
Practice Address - Street 1:6473 KINGSTON PIKE STE 6473
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4832
Practice Address - Country:US
Practice Address - Phone:616-459-4171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X
TN4965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care