Healthcare Provider Details

I. General information

NPI: 1285645044
Provider Name (Legal Business Name): HEATH RUSSELL RENNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 OAKDALE AVE N SUITE 103
ROBBINSDALE MN
55422-2948
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 900
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 763-520-7870
  • Fax: 763-520-7580
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9757
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: