Provider Demographics
NPI:1285645044
Name:RENNER, HEATH RUSSELL (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:RUSSELL
Last Name:RENNER
Suffix:
Gender:M
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 1:6465 WAYZATA BLVD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1728
Mailing Address - Country:US
Mailing Address - Phone:952-512-5600
Mailing Address - Fax:952-512-5650
Practice Address - Street 1:3366 OAKDALE AVE N
Practice Address - Street 2:SUITE 103
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2948
Practice Address - Country:US
Practice Address - Phone:763-520-7870
Practice Address - Fax:763-520-7580
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
969991033651OtherPREFERREDONE
065G8REOtherBLUECROSS BLUESHIELD
116980OtherMEDICA
13138C564OtherUCARE
HP39821OtherHEALTHPARTNERS
969991033651OtherPREFERREDONE