Provider Demographics
NPI:1679142152
Name:GREENE, ISAIAH J (PT, DPT)
Entity type:Individual
Prefix:
First Name:ISAIAH
Middle Name:J
Last Name:GREENE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2622
Mailing Address - Country:US
Mailing Address - Phone:701-293-6037
Mailing Address - Fax:701-293-0242
Practice Address - Street 1:1461 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2622
Practice Address - Country:US
Practice Address - Phone:701-293-6037
Practice Address - Fax:701-293-0242
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2518225100000X
CO2518225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist