Provider Demographics
NPI:1972673895
Name:VINYARD, RENEE (PA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:VINYARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4560
Mailing Address - Country:US
Mailing Address - Phone:707-463-7356
Mailing Address - Fax:707-462-4409
Practice Address - Street 1:234 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4560
Practice Address - Country:US
Practice Address - Phone:707-463-7356
Practice Address - Fax:707-462-4409
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS77136Medicare UPIN