Provider Demographics
NPI:1871681213
Name:GREENE, GREGORY CLARK (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CLARK
Last Name:GREENE
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 1:9125 CROSS PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4563
Mailing Address - Country:US
Mailing Address - Phone:865-632-5900
Mailing Address - Fax:865-637-2114
Practice Address - Street 1:101 E BLOUNT AVE STE 800
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1669
Practice Address - Country:US
Practice Address - Phone:865-632-5900
Practice Address - Fax:865-637-2114
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA400363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666163Medicaid
TN3046774OtherBCBSTN
TN3046774OtherBCBSTN
TNR93284Medicare UPIN