Provider Demographics
NPI:1053704361
Name:RENTERIA, JOSE LUIS (ACNP)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:RENTERIA
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 ODELL ST
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-2419
Mailing Address - Country:US
Mailing Address - Phone:620-786-8783
Mailing Address - Fax:
Practice Address - Street 1:1905 19TH ST
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-2502
Practice Address - Country:US
Practice Address - Phone:620-792-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-76710-092363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care