Basic Information
| Provider Information | |||||||||
| NPI: | 1124636113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | SHELLIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COUNTRYMAN | ||||||||
| OtherFirstName: | SHELLIE | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2697 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142141701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853718373 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 160 STONE ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136013250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853718373 | ||||||||
| FaxNumber: | 3152227435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2020 | ||||||||
| LastUpdateDate: | 07/17/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F346037-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.