Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 170100000X | Medical Geneticist | ||
Y | 207Q00000X | Family Doctor | 0101235756 | VA |
NPI | 1144203308 |
---|---|
Provider Name | Matthew Peter Green |
First Address | Charlottesville, VA 22906-9007 |
Second Address | Louisa, VA 23093-4146 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/11/2005 |
Last Update Date | 31/07/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1144203308 | (05) | VA |
I03426 | (02) | VA |