Provider Demographics
NPI:1780646398
Name:URSUY, RENEE L (PA-C)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:L
Last Name:URSUY
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 1:2715 TAVERN CT
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9586
Mailing Address - Country:US
Mailing Address - Phone:786-338-0478
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1000
Practice Address - Country:US
Practice Address - Phone:336-938-0800
Practice Address - Fax:336-938-0755
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2531YMedicare ID - Type Unspecified
FLQ16099Medicare UPIN