Provider Demographics
NPI:1245279405
Name:GREEN, TANYA RENITA (PA)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENITA
Last Name:GREEN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3116
Mailing Address - Country:US
Mailing Address - Phone:815-288-5531
Mailing Address - Fax:815-285-5558
Practice Address - Street 1:68 HARRIS RD
Practice Address - Street 2:
Practice Address - City:HARRIS
Practice Address - State:NY
Practice Address - Zip Code:12742-5030
Practice Address - Country:US
Practice Address - Phone:845-794-3300
Practice Address - Fax:845-794-3240
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06905363A00000X
IL085002921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2921863-00Medicaid
Q41024Medicare UPIN
FLU4524UMedicare PIN