Provider Demographics
NPI:1730137548
Name:KNUTSON, RENEE A (PA-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:A
Last Name:KNUTSON
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 1:38 HIDDEN HOLLOW TRL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:38 HIDDEN HOLLOW TRL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2501
Practice Address - Country:US
Practice Address - Phone:608-669-6862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI725363AM0700X
WI725-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42945500Medicaid
WI4204OtherDEAN HEALTH INSURANCE
S58875Medicare UPIN
WI053474150Medicare PIN
WI970011968Medicare PIN
WI42945500Medicaid