Provider Demographics
NPI:1851303622
Name:DERENNE, SCOTT R (PA-C (PHYSICIAN ASSI)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:DERENNE
Suffix:
Gender:M
Credentials:PA-C (PHYSICIAN ASSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15225 S 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85045-1904
Mailing Address - Country:US
Mailing Address - Phone:920-737-4014
Mailing Address - Fax:920-288-8355
Practice Address - Street 1:15225 S 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85045-1904
Practice Address - Country:US
Practice Address - Phone:920-737-4014
Practice Address - Fax:920-288-8355
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI913363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42967700Medicaid
WI008207650Medicare ID - Type Unspecified
S26448Medicare UPIN