Provider Demographics
NPI:1780664474
Name:MCCONNELL, RENAE K (PA-C)
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:K
Last Name:MCCONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1862
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:28080 GRAND RIVER AVE
Practice Address - Street 2:SUITE 300W
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5966
Practice Address - Country:US
Practice Address - Phone:248-615-7300
Practice Address - Fax:248-615-7333
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003985363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53572Medicare UPIN