Provider Demographics
NPI:1689282618
Name:GREENE, JOHNNY
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:
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 623
Mailing Address - Street 2:
Mailing Address - City:OAKLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94561-0623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2623 E SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2926
Practice Address - Country:US
Practice Address - Phone:323-583-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA60202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program