Basic Information
| Provider Information | |||||||||
| NPI: | 1740456706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENLEY OAKS EAR, NOSE & THROAT, APC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 795 MORNING STAR DR | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095332545 | ||||||||
| FaxNumber: | 2095330924 | ||||||||
| Practice Location | |||||||||
| Address1: | 795 MORNING STAR DR | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095332545 | ||||||||
| FaxNumber: | 2095330924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLMAN | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2095332545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00G317680 | 05 | CA | MEDICAID | 00G670890 | 05 | CA | MEDICAID |