Healthcare Provider Details

I. General information

NPI: 1265951354
Provider Name (Legal Business Name): AUSTIN JAMES RENAUD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 INDUSTRIAL PARK ROAD
NIANTIC CT
06357-1904
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-7345
  • Fax:
Mailing address:
  • Phone: 919-220-5255
  • Fax: 919-220-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16843
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: