Provider Demographics
NPI:1699843581
Name:FISKE, RENNYE L (PA-C)
Entity type:Individual
Prefix:
First Name:RENNYE
Middle Name:L
Last Name:FISKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 W 66TH ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2111
Mailing Address - Country:US
Mailing Address - Phone:952-832-0805
Mailing Address - Fax:952-832-5597
Practice Address - Street 1:6405 FRANCE AVE S
Practice Address - Street 2:SUITE W440
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2163
Practice Address - Country:US
Practice Address - Phone:952-927-7004
Practice Address - Fax:952-927-5146
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2016-02-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9563363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical