Provider Demographics
NPI:1588653935
Name:ALWAN PERCELL, RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:ALWAN PERCELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:ALWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2101
Mailing Address - Country:US
Mailing Address - Phone:309-664-3000
Mailing Address - Fax:309-664-3026
Practice Address - Street 1:1701 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2101
Practice Address - Country:US
Practice Address - Phone:309-664-3000
Practice Address - Fax:309-664-3026
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2613OtherMEDICARE GROUP NUMBER
AZ031815OtherMEDICARE
AZ031820OtherMEDICARE
AZ3289OtherLICENSE
AZ031813OtherMEDICARE
AZ031814OtherMEDICARE
AZ031814OtherMEDICARE
106565Medicare PIN
AZ031815OtherMEDICARE