Provider Demographics
NPI:1972955813
Name:GREEN, JOHN (RN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10652 STATE ROUTE 149
Mailing Address - Street 2:
Mailing Address - City:FORT ANN
Mailing Address - State:NY
Mailing Address - Zip Code:12827-1906
Mailing Address - Country:US
Mailing Address - Phone:518-791-8941
Mailing Address - Fax:
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-04
Last Update Date:2016-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694511282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital