Healthcare Provider Details

I. General information

NPI: 1184670101
Provider Name (Legal Business Name): RICHARD RENNER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 ROUTE 108
SOMERSWORTH NH
03878-1543
US

IV. Provider business mailing address

107 COMMERCIAL ST
MASHPEE MA
02649-6507
US

V. Phone/Fax

Practice location:
  • Phone: 603-692-4018
  • Fax: 603-692-1083
Mailing address:
  • Phone: 508-539-6000
  • Fax: 508-477-7028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0075P
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA633
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: