Basic Information
| Provider Information | |||||||||
| NPI: | 1528175049 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MSN, CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRIDER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, MSN, CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2340 BETHEL CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | BETHEL PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151022978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 4128312407 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BRINTON RD | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152214533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4129772431 | ||||||||
| FaxNumber: | 8888168109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 04/13/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | TP006399B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 364SF0001X | TP006399B | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
| ID | Type | State | Issuer | Description | TP006399B | 01 | PA | LICENSE | OTHER |