Healthcare Provider Details

I. General information

NPI: 1932189636
Provider Name (Legal Business Name): RENE A FERNETTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 PHALEN BLVD
SAINT PAUL MN
55130-2400
US

IV. Provider business mailing address

PO BOX 1309 - 8170 33RD AVE S MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-495-6600
  • Fax: 952-883-9677
Mailing address:
  • Phone: 651-254-3490
  • Fax: 651-254-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1640
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2455
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601002403
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11636
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: