Provider Demographics
NPI:1821725615
Name:RENKEN, BROCK MICHAEL
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:MICHAEL
Last Name:RENKEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 FOUR STATES DR STE 1
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-4325
Mailing Address - Country:US
Mailing Address - Phone:877-783-4441
Mailing Address - Fax:
Practice Address - Street 1:444 FOUR STATES DR STE 1
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-4325
Practice Address - Country:US
Practice Address - Phone:877-783-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5478363A00000X
KS15-03048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant