Provider Demographics
NPI:1730189861
Name:GREEN, CHERYL R (PA)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:R
Last Name:GREEN
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Gender:F
Credentials:PA
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Mailing Address - Street 1:350 HERITAGE WAY
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3158
Mailing Address - Country:US
Mailing Address - Phone:406-257-8992
Mailing Address - Fax:406-257-8996
Practice Address - Street 1:350 HERITAGE WAY
Practice Address - Street 2:SUITE 2100
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3158
Practice Address - Country:US
Practice Address - Phone:406-257-8992
Practice Address - Fax:406-257-8996
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2023-11-27
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Provider Licenses
StateLicense IDTaxonomies
OKAPA1318363AM0700X
MT40815363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ13855Medicare UPIN