Provider Demographics
NPI:1013191931
Name:RENEAU, JEREMY J (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:RENEAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9149
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9149
Mailing Address - Country:US
Mailing Address - Phone:304-293-7095
Mailing Address - Fax:
Practice Address - Street 1:1 AMALIA DR
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2239
Practice Address - Country:US
Practice Address - Phone:304-473-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant