Basic Information
| Provider Information | |||||||||
| NPI: | 1922123835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENTREE | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENTREE | ||||||||
| OtherFirstName: | GORDON | ||||||||
| OtherMiddleName: | ERIC | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 175 COUNTY ROAD 469 | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783329207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616683003 | ||||||||
| FaxNumber: | 3613947158 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 SOUTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FREER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783571750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613947311 | ||||||||
| FaxNumber: | 3613947158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | TXPA00041 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.