Provider Demographics
NPI:1679585517
Name:GREEN, SEAN E (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:E
Last Name:GREEN
Suffix:
Gender:M
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 1:911 23RD ST
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4600
Mailing Address - Country:US
Mailing Address - Phone:806-655-2104
Mailing Address - Fax:806-655-0522
Practice Address - Street 1:911 23RD ST
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4600
Practice Address - Country:US
Practice Address - Phone:806-655-2104
Practice Address - Fax:806-655-0522
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129700101OtherFIRST CARE
TX129700101OtherSOUTHWEST LIFE & HEALTH
TX8N8379OtherBCBS
TX129700101OtherSOUTHWEST LIFE & HEALTH
TX8E0564Medicare PIN
TX8N8379OtherBCBS