Basic Information
Provider Information | |||||||||
NPI: | 1285645044 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RENNER | ||||||||
FirstName: | HEATH | ||||||||
MiddleName: | RUSSELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6465 WAYZATA BLVD | ||||||||
Address2: | SUITE 900 | ||||||||
City: | ST LOUIS PARK | ||||||||
State: | MN | ||||||||
PostalCode: | 554261728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9525125600 | ||||||||
FaxNumber: | 9525125650 | ||||||||
Practice Location | |||||||||
Address1: | 3366 OAKDALE AVE N | ||||||||
Address2: | SUITE 103 | ||||||||
City: | ROBBINSDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 554222948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635207870 | ||||||||
FaxNumber: | 7635207580 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 07/11/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9757 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 969991033651 | 01 |   | PREFERREDONE | OTHER | 065G8RE | 01 |   | BLUECROSS BLUESHIELD | OTHER | 116980 | 01 |   | MEDICA | OTHER | 13138C564 | 01 |   | UCARE | OTHER | HP39821 | 01 |   | HEALTHPARTNERS | OTHER |