Provider Demographics
NPI:1487913828
Name:RENNA, ALICIA FRANCES (PA-C)
Entity type:Individual
Prefix:MISS
First Name:ALICIA
Middle Name:FRANCES
Last Name:RENNA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:FRANCES
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:405 S NEWTOWN STREET RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-4411
Mailing Address - Country:US
Mailing Address - Phone:845-417-7770
Mailing Address - Fax:
Practice Address - Street 1:217 REECEVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320-1572
Practice Address - Country:US
Practice Address - Phone:610-384-6076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055477363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034580900001Medicaid