Provider Demographics
NPI:1760493811
Name:KROUPA, RENETTE LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:RENETTE
Middle Name:LYNNE
Last Name:KROUPA
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 1:36980 239TH ST
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57383-5013
Mailing Address - Country:US
Mailing Address - Phone:605-249-2525
Mailing Address - Fax:
Practice Address - Street 1:HWY 34/47
Practice Address - Street 2:
Practice Address - City:FORT THOMPSON
Practice Address - State:SD
Practice Address - Zip Code:57339
Practice Address - Country:US
Practice Address - Phone:605-245-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0155363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical