Provider Demographics
NPI:1700429925
Name:GREEN, TRAVIS (CRNP)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 N CEDAR CREST BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2323
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:3701 CORRIERE RD STE 10
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-7991
Practice Address - Country:US
Practice Address - Phone:484-591-7205
Practice Address - Fax:484-591-7206
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily