Provider Demographics
NPI:1851022107
Name:RENTERIA LOERA, BRENDA (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:RENTERIA LOERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:
Other - Last Name:RENTERIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 POLE LINE RD W STE 3880
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5811
Practice Address - Country:US
Practice Address - Phone:208-814-8500
Practice Address - Fax:208-814-8960
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IDPA-2663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant