Basic Information
| Provider Information | |||||||||
| NPI: | 1699916130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2790 CLAY EDWARDS DR | ||||||||
| Address2: | STE 600 | ||||||||
| City: | N KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165613003 | ||||||||
| FaxNumber: | 8168891584 | ||||||||
| Practice Location | |||||||||
| Address1: | 2790 CLAY EDWARDS DR | ||||||||
| Address2: | STE 600 | ||||||||
| City: | N KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641163276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165613003 | ||||||||
| FaxNumber: | 8168891584 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2009 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2009005434 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 2009005434 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.