Provider Demographics
NPI:1093135246
Name:RENNER, MEGAN KAYLA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:KAYLA
Last Name:RENNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 PALMETTO LAKE DR
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-2998
Mailing Address - Country:US
Mailing Address - Phone:850-686-6257
Mailing Address - Fax:
Practice Address - Street 1:1703 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1221
Practice Address - Country:US
Practice Address - Phone:850-686-6257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108720363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical