Provider Demographics
NPI:1609879782
Name:GREENE, KRISTINA RENAE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:RENAE
Last Name:GREENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-851-6033
Mailing Address - Fax:615-296-9935
Practice Address - Street 1:980 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5251
Practice Address - Country:US
Practice Address - Phone:931-905-1001
Practice Address - Fax:931-905-0410
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3667492Medicaid
TNP00433226OtherMEDICARE RAILROAD
P22123Medicare UPIN
TN3667492Medicaid