Basic Information
| Provider Information | |||||||||
| NPI: | 1548592355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5219 CITY BANK PKWY STE 35 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067610333 | ||||||||
| FaxNumber: | 8067857685 | ||||||||
| Practice Location | |||||||||
| Address1: | 6205 43RD ST # 100 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794073828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067492263 | ||||||||
| FaxNumber: | 8067492264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2010 | ||||||||
| LastUpdateDate: | 03/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06453 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 213074202 | 05 | TX | MEDICAID |