MEDICARE: SCOTT R DERENNE PA-C (PHYSICIAN ASSI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	913	WI
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1851303622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT R DERENNE PA-C (PHYSICIAN ASSI

Provider Business Mailing Address
First Line	:	15225 S 15TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-1904
Country	:	US
Telephone Number	:	920-737-4014
Fax Number	:	920-288-8355

Provider Business Practice Location Address
First Line	:	15225 S 15TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85045-1904
Country	:	US
Telephone Number	:	920-737-4014
Fax Number	:	920-288-8355

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/10/2019

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