Provider Demographics
NPI:1841764289
Name:GREENE, MICHAEL CAYMAN (ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CAYMAN
Last Name:GREENE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 E CORTLAND BLVD APT 174
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-9314
Mailing Address - Country:US
Mailing Address - Phone:575-640-1041
Mailing Address - Fax:
Practice Address - Street 1:5205 E CORTLAND BLVD APT 174
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-9314
Practice Address - Country:US
Practice Address - Phone:575-640-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2020-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000035823OtherATHLETIC TRAINER - BOARD OF CERTIFICATION