Provider Demographics
NPI:1669523718
Name:MILLER, RENAE L (PA-C)
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1361 WENNER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7918
Mailing Address - Country:US
Mailing Address - Phone:218-396-6500
Mailing Address - Fax:218-396-6504
Practice Address - Street 1:1361 WENNER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-7918
Practice Address - Country:US
Practice Address - Phone:218-396-6500
Practice Address - Fax:218-396-6504
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9386363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9386OtherSTATE OF MN PA LICENSE
1033355OtherNCCPA-NAT.COMM.CERT.PA
S33359Medicare UPIN
970002284Medicare ID - Type UnspecifiedWPS PARTB CMS