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Individual
MRS. TABETHA BROOME RENNER
Active
Individual
MRS. TABETHA BROOME RENNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-AC
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
Primary
05414
GA
367H00000X
Anesthesiologist Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
578310
WELLCARE
GA
01
—
580628385
TRICARE
GA
05
—
606097755D
—
GA
05
—
606097755E
—
GA
05
—
606097755F
—
GA
05
—
606097755G
—
GA
01
—
P01101055
RAILROAD MEDICARE
GA
Enumeration date
08/07/2008
Last updated
04/13/2022
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