Provider Demographics
NPI:1801288063
Name:GREEN, ASPEN NICOLE (CNM)
Entity type:Individual
Prefix:
First Name:ASPEN
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:ASPEN
Other - Middle Name:NICOLE
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2013 CERVIN BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-5430
Mailing Address - Country:US
Mailing Address - Phone:702-332-1783
Mailing Address - Fax:
Practice Address - Street 1:919 E 32ND ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-2703
Practice Address - Country:US
Practice Address - Phone:512-476-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127473367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154785301Medicaid
TX8757B7Medicare PIN