Provider Demographics
NPI:1295540821
Name:GREEN, RANDALL DEVIN JR
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DEVIN
Last Name:GREEN
Suffix:JR
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 1:5036 OLD MOUNTAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-5464
Mailing Address - Country:US
Mailing Address - Phone:302-354-9927
Mailing Address - Fax:
Practice Address - Street 1:5036 OLD MOUNTAIN RD NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-5464
Practice Address - Country:US
Practice Address - Phone:302-354-9927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE0001255155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily