Basic Information
| Provider Information | |||||||||
| NPI: | 1679832265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 E 31ST ST | ||||||||
| Address2: | QIC 22134 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104374965 | ||||||||
| FaxNumber: | 5104375127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 E 31ST ST | ||||||||
| Address2: | QIC 22134 | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946021018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104374965 | ||||||||
| FaxNumber: | 5104375127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.