Provider Demographics
NPI:1679144265
Name:RENOUARD, ELIZABETH SPENCER (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SPENCER
Last Name:RENOUARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3366 NW EXPRESSWAY STE 250
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4427
Mailing Address - Country:US
Mailing Address - Phone:405-552-0401
Mailing Address - Fax:
Practice Address - Street 1:3366 NW EXPRESSWAY STE 250
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4427
Practice Address - Country:US
Practice Address - Phone:405-552-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty