Provider Demographics
NPI:1881679595
Name:GREEN, STEPHEN MARK (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:GREEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W LOUIS HENNA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-1203
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2105
Practice Address - Country:US
Practice Address - Phone:806-350-7918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA123016367500000X
NH059893-23367500000X
VT101-0032498367500000X
OR201260025CRNA367500000X
TX1082367500000X
MARN271326367500000X
WAAP30004631367500000X
NM73353367500000X
TXAP109124367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX430078925OtherMEDICARE RAILROAD
47-0891118OtherTAX ID
TX83485UOtherBLUE CROSS BLUE SHIELD
TX161131101Medicaid
47-0891118OtherTAX ID
TX161131101OtherSUPERIOR CHIP
47-0891118OtherTAX ID
S70180Medicare UPIN