Provider Demographics
NPI:1720831183
Name:GREEN, GASTIN
Entity Type:Individual
Prefix:
First Name:GASTIN
Middle Name:
Last Name:GREEN
Suffix:
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 1:9781 HARRIOTT RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9533
Mailing Address - Country:US
Mailing Address - Phone:740-833-5707
Mailing Address - Fax:
Practice Address - Street 1:11780 WATKINS RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8708
Practice Address - Country:US
Practice Address - Phone:740-833-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty