Provider Demographics
NPI:1962448480
Name:GREEN, CHANCE (CRNA)
Entity type:Individual
Prefix:
First Name:CHANCE
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:135 N CENTER ST UNIT 5870
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85211-7159
Mailing Address - Country:US
Mailing Address - Phone:480-874-7014
Mailing Address - Fax:480-874-7015
Practice Address - Street 1:5448 HIGHWAY 260 STE 100
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5736
Practice Address - Country:US
Practice Address - Phone:928-359-1862
Practice Address - Fax:928-537-2049
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28162181367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200513510Medicaid