Provider Demographics
NPI:1730952128
Name:TRISTAO GREEN, MARIANA (CNM)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:TRISTAO GREEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARIANA
Other - Middle Name:
Other - Last Name:TRISTAO SABA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5024 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5552
Mailing Address - Country:US
Mailing Address - Phone:239-825-0345
Mailing Address - Fax:
Practice Address - Street 1:694 GOOD DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-2433
Practice Address - Country:US
Practice Address - Phone:717-397-8177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010760207V00000X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology