Provider Demographics
NPI:1174726228
Name:RENZI, MICHELLE A (RPA-C)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:RENZI
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 S CENTRAL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5437
Mailing Address - Country:US
Mailing Address - Phone:516-791-8664
Mailing Address - Fax:
Practice Address - Street 1:30 S CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5437
Practice Address - Country:US
Practice Address - Phone:516-791-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant