Provider Demographics
NPI:1649851080
Name:GREEN, BRIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:
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 1:201 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3658
Mailing Address - Country:US
Mailing Address - Phone:307-674-6995
Mailing Address - Fax:
Practice Address - Street 1:201 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3658
Practice Address - Country:US
Practice Address - Phone:307-674-6995
Practice Address - Fax:307-459-5908
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA1029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical