Provider Demographics
NPI:1861636375
Name:RENKEN, CLARISSA J (DO)
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:J
Last Name:RENKEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 PLAZA DR
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR
Practice Address - Street 2:SUITE 1300
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4158
Practice Address - Country:US
Practice Address - Phone:715-847-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
WI54752-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program