Provider Demographics
NPI:1689316796
Name:GREEN, TAREYN LYN
Entity Type:Individual
Prefix:
First Name:TAREYN
Middle Name:LYN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 W PULLMAN RD
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-4012
Mailing Address - Country:US
Mailing Address - Phone:208-883-8372
Mailing Address - Fax:
Practice Address - Street 1:300 MONTICELLO AVE STE B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-5616
Practice Address - Country:US
Practice Address - Phone:434-544-8876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant