Provider Demographics
NPI:1790073393
Name:ROSS, RENEE HYMEL (PA-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:HYMEL
Last Name:ROSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:LYNN
Other - Last Name:HYMEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-3970
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04682011Medicaid
LA2335511Medicaid
LA2335511Medicaid