Provider Demographics
NPI:1871545731
Name:RENNER, LAURA E (ANP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:RENNER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N GRAHAM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1683
Mailing Address - Country:US
Mailing Address - Phone:503-413-4134
Mailing Address - Fax:503-413-1895
Practice Address - Street 1:300 N GRAHAM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1683
Practice Address - Country:US
Practice Address - Phone:503-413-4134
Practice Address - Fax:503-413-1895
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000033925N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
500003758OtherRR PIN #
OR77206Medicaid
112394Medicare ID - Type Unspecified
S49218Medicare UPIN