Provider Demographics
NPI:1255723110
Name:GREEN, COREY NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
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 1:30208 WACO RD
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-9012
Mailing Address - Country:US
Mailing Address - Phone:405-245-8581
Mailing Address - Fax:
Practice Address - Street 1:29501 KICKAPOO RD
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851-8320
Practice Address - Country:US
Practice Address - Phone:405-964-3020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant