Basic Information
| Provider Information | |||||||||
| NPI: | 1871681213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9125 CROSS PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656325900 | ||||||||
| FaxNumber: | 8656372114 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E BLOUNT AVE STE 800 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379201669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656325900 | ||||||||
| FaxNumber: | 8656372114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA400 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3666163 | 05 | TN | MEDICAID | 3046774 | 01 | TN | BCBSTN | OTHER |