Provider Demographics
NPI:1659335453
Name:RENNER, DAVID R (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:RENNER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:623 E BROAD ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18018-6332
Mailing Address - Country:US
Mailing Address - Phone:610-954-6048
Mailing Address - Fax:610-954-3189
Practice Address - Street 1:800 OSTRUM ST
Practice Address - Street 2:STE 202
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1015
Practice Address - Country:US
Practice Address - Phone:610-807-9400
Practice Address - Fax:610-997-6326
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA001272L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR07480Medicare UPIN
PA049457Medicare ID - Type UnspecifiedMEDICARE