Provider Demographics
NPI:1942307400
Name:MILLS, RENNIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:RENNIE
Middle Name:
Last Name:MILLS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-4540
Practice Address - Fax:601-984-4548
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTPA0028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01383764Medicaid
FL291934600Medicaid
FLE1377WMedicare PIN
MS445094YJ5DMedicare PIN
DCS65552Medicare UPIN
FLE1377ZMedicare PIN