Provider Demographics
NPI:1760669683
Name:WILTERDING, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:WILTERDING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:ARMISTEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7772 GOLD BUCKLE CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5858
Mailing Address - Country:US
Mailing Address - Phone:909-425-1932
Mailing Address - Fax:
Practice Address - Street 1:7772 GOLD BUCKLE CT
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-5858
Practice Address - Country:US
Practice Address - Phone:909-425-1932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19529363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical