Provider Demographics
NPI:1053371740
Name:COLEMAN, RENEE L (PAC)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:L
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:L
Other - Last Name:HEINEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:331 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-679-1313
Practice Address - Fax:320-225-3141
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R92617Medicare UPIN