Provider Demographics
NPI:1780757948
Name:RENNER, LUCINDA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LUCINDA
Middle Name:MARIE
Last Name:RENNER
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 1:310 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4516
Mailing Address - Country:US
Mailing Address - Phone:701-530-7500
Mailing Address - Fax:701-530-7484
Practice Address - Street 1:310 N 10TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4516
Practice Address - Country:US
Practice Address - Phone:701-530-7500
Practice Address - Fax:701-530-7484
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND31061OtherBCBSND
ND1780757948OtherNPI
713488Medicare PIN
ND1780757948OtherNPI
ND31061OtherBCBSND