Provider Demographics
NPI:1184670101
Name:RENNER, RICHARD (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:RENNER
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 1:107 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-6507
Mailing Address - Country:US
Mailing Address - Phone:508-539-6000
Mailing Address - Fax:508-477-7028
Practice Address - Street 1:255 ROUTE 108
Practice Address - Street 2:
Practice Address - City:SOMERSWORTH
Practice Address - State:NH
Practice Address - Zip Code:03878-1543
Practice Address - Country:US
Practice Address - Phone:603-692-4018
Practice Address - Fax:603-692-1083
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0075P363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003861Medicaid
NHAP0204Medicare PIN
NH30003861Medicaid