Provider Demographics
NPI:1639241110
Name:GREENE, FREDERICK SAMUEL (PAC)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:SAMUEL
Last Name:GREENE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:AK
Mailing Address - Zip Code:99660-0148
Mailing Address - Country:US
Mailing Address - Phone:907-546-8300
Mailing Address - Fax:
Practice Address - Street 1:1000 POLIVENIA TPKE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL ISLAND
Practice Address - State:AK
Practice Address - Zip Code:99660
Practice Address - Country:US
Practice Address - Phone:907-546-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDA0151Medicaid