Provider Demographics
NPI:1932189636
Name:FERNETTE, RENE A (PA-C)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:A
Last Name:FERNETTE
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:PO BOX 1309 - 8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-3490
Mailing Address - Fax:651-254-7033
Practice Address - Street 1:295 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-2400
Practice Address - Country:US
Practice Address - Phone:651-495-6600
Practice Address - Fax:952-883-9677
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1640363A00000X
WI2455363A00000X
MI5601002403363AS0400X
MN11636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932189636Medicaid
OK200116670AMedicaid
WI453000627Medicare PIN
OK246720806Medicare PIN
OK200116670AMedicaid