Provider Demographics
NPI:1255302717
Name:WRENN, ROMEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMEL
Middle Name:C
Last Name:WRENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-458-6450
Mailing Address - Fax:907-458-6430
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-458-6450
Practice Address - Fax:907-458-6430
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA014701207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366269Medicaid
LA060067787OtherRAILROAD MEDICARE
LA53216Medicare ID - Type Unspecified
LA1366269Medicaid