Provider Demographics
NPI:1295764892
Name:GREEN, ROGER A (ARNP)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 S MCCARRAN BLVD STE A12
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6114
Mailing Address - Country:US
Mailing Address - Phone:775-221-7400
Mailing Address - Fax:
Practice Address - Street 1:6630 S MCCARRAN BLVD STE A12
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6114
Practice Address - Country:US
Practice Address - Phone:775-221-7400
Practice Address - Fax:775-657-6551
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2829342363L00000X
NVAPRN002022363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner