Provider Demographics
NPI:1598792558
Name:GREEN, THERESA (ANESTHESIOLOGIST AST)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ANESTHESIOLOGIST AST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 FETKE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8649
Mailing Address - Country:US
Mailing Address - Phone:269-408-1114
Mailing Address - Fax:
Practice Address - Street 1:900 PEELER ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-2380
Practice Address - Country:US
Practice Address - Phone:269-345-0244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant