Basic Information
| Provider Information | |||||||||
| NPI: | 1467417196 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MILTON | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 34TH AVE S | ||||||||
| Address2: | 21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837961 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 JACKSON STREET | ||||||||
| Address2: | MAIL STOP 11503P | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
| FaxNumber: | 6512543048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 06/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R1381951 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 821748300 | 05 | MN | MEDICAID |