Basic Information
| Provider Information | |||||||||
| NPI: | 1790856581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | LONNIE | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3431 KNIGHT ST | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115724638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166088387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27005 76TH AVE | ||||||||
| Address2: | LONG ISLAND JEWISH MEDICAL CENTER | ||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184707000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/30/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010707-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 010707 | 01 | NY | LICENSE NUMBER | OTHER |