Provider Demographics
NPI:1134163868
Name:GREEN, MARCIA W (FNP)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:W
Last Name:GREEN
Suffix:
Gender:
Credentials:FNP
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:520 E DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8307
Practice Address - Country:US
Practice Address - Phone:903-593-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660992363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202278201Medicaid
TX202278201Medicaid
TX8G6555Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE NO.
TX8G6555Medicare Oscar/Certification