Healthcare Provider Details

I. General information

NPI: 1487810610
Provider Name (Legal Business Name): TABETHA BROOME RENNER PA-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TABETHA BROOME RAGIN PA

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CHARTER BLVD
MACON GA
31210-4831
US

IV. Provider business mailing address

PO BOX 2564
MACON GA
31203-2565
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-7577
  • Fax:
Mailing address:
  • Phone: 478-746-5644
  • Fax: 478-745-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number05414
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: