Provider Demographics
NPI:1811123862
Name:GREEN, MARK RYAN (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RYAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29185 HIGHWAY 191
Mailing Address - Street 2:
Mailing Address - City:MANY
Mailing Address - State:LA
Mailing Address - Zip Code:71449-6313
Mailing Address - Country:US
Mailing Address - Phone:318-590-9140
Mailing Address - Fax:318-590-9141
Practice Address - Street 1:29185 HIGHWAY 191
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-6313
Practice Address - Country:US
Practice Address - Phone:318-590-9140
Practice Address - Fax:318-590-9141
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3B124CA35Medicare PIN