Provider Demographics
NPI:1407903743
Name:RENN, AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:RENN
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:PO BOX 1833
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-1833
Mailing Address - Country:US
Mailing Address - Phone:919-331-2477
Mailing Address - Fax:919-331-2481
Practice Address - Street 1:185 RAWLS ROAD
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501
Practice Address - Country:US
Practice Address - Phone:919-331-2477
Practice Address - Fax:919-331-2481
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP65219Medicare UPIN
NC2755757BMedicare PIN