Healthcare Provider Details

I. General information

NPI: 1740055912
Provider Name (Legal Business Name): MATTHEW LANE RENNER PA-STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 W 20TH ST
GREELEY CO
80634-3037
US

IV. Provider business mailing address

19 FOSTER ST
WORCESTER MA
01608-1715
US

V. Phone/Fax

Practice location:
  • Phone: 970-744-0279
  • Fax:
Mailing address:
  • Phone: 970-744-0279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009086
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: