Provider Demographics
NPI:1467497487
Name:MATTHEWS, RENAE J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RENAE
Middle Name:J
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:704-688-9651
Practice Address - Street 1:711 DELMORE DR- ALTRU CLINIC/ROSEAU
Practice Address - Street 2:
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1534
Practice Address - Country:US
Practice Address - Phone:218-463-1365
Practice Address - Fax:704-688-9651
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN12915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S71781Medicare UPIN
2755409Medicare ID - Type Unspecified
P00068553Medicare PIN
2755409AMedicare PIN