Provider Demographics
NPI:1043374259
Name:GREEN, MEGHAN SUZANNE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:SUZANNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14001 RIDGEDALE DR
Mailing Address - Street 2:#100
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1781
Mailing Address - Country:US
Mailing Address - Phone:952-473-0211
Mailing Address - Fax:952-473-7908
Practice Address - Street 1:111 HUNDERTMARK RD
Practice Address - Street 2:#420
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1459
Practice Address - Country:US
Practice Address - Phone:952-448-3847
Practice Address - Fax:952-448-5083
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381703363LP0200X
MNR226548-7363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02576878Medicaid
NYP019381703OtherBLUE CHOICE
NY149194DLOtherPREFERRED CARE