Provider Demographics
NPI:1225923931
Name:GREEN, NATHANAEL GIDEON
Entity type:Individual
Prefix:
First Name:NATHANAEL
Middle Name:GIDEON
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23072 LAKE CENTER DR STE 115
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2880
Mailing Address - Country:US
Mailing Address - Phone:949-406-9694
Mailing Address - Fax:
Practice Address - Street 1:23072 LAKE CENTER DR STE 115
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2880
Practice Address - Country:US
Practice Address - Phone:949-406-9694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MPSS-UCZFAE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist