Provider Demographics
NPI:1366539728
Name:GREEN, RICHARD W (FNP)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:GREEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000 DEPT 19
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-386-4423
Mailing Address - Fax:901-333-8056
Practice Address - Street 1:2996 KATE BOND RD
Practice Address - Street 2:SUITE 405
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4030
Practice Address - Country:US
Practice Address - Phone:901-386-4423
Practice Address - Fax:901-333-8056
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS84160Medicare UPIN
TN3903709Medicare ID - Type Unspecified