Basic Information
| Provider Information | |||||||||
| NPI: | 1073859401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KRISTIAN | ||||||||
| MiddleName: | ASHLEY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | BOX 78534 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532788534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Practice Location | |||||||||
| Address1: | 1435 N RANDALL RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601232302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153989491 | ||||||||
| FaxNumber: | 8153817498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085.004557 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085004557 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.