Provider Demographics
NPI:1841438959
Name:PRIVETT, RENEE JEANINE (PA-C)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:JEANINE
Last Name:PRIVETT
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 1:2121 W CHANDLER BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6545
Mailing Address - Country:US
Mailing Address - Phone:480-963-2233
Mailing Address - Fax:480-963-2277
Practice Address - Street 1:2121 W CHANDLER BLVD
Practice Address - Street 2:STE 110
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6545
Practice Address - Country:US
Practice Address - Phone:480-963-2233
Practice Address - Fax:480-963-2277
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2700363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ501958Medicaid
AZ3Z3974OtherHEALTHNET
AZ3Z3974OtherHEALTHNET
AZP00845770Medicare PIN