Provider Demographics
NPI:1487810610
Name:RENNER, TABETHA BROOME (PA-AC)
Entity type:Individual
Prefix:MRS
First Name:TABETHA
Middle Name:BROOME
Last Name:RENNER
Suffix:
Gender:F
Credentials:PA-AC
Other - Prefix:
Other - First Name:TABETHA
Other - Middle Name:BROOME
Other - Last Name:RAGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203-2565
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:400 CHARTER BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4831
Practice Address - Country:US
Practice Address - Phone:478-746-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
GA05414367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA606097755DMedicaid
GA606097755GMedicaid
GA580628385OtherTRICARE
GAP01101055OtherRAILROAD MEDICARE
GA606097755EMedicaid
GA606097755FMedicaid
GA578310OtherWELLCARE
GA606097755EMedicaid