Healthcare Provider Details

I. General information

NPI: 1174726228
Provider Name (Legal Business Name): MICHELLE A. RENZI RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S CENTRAL AVE STE 201
VALLEY STREAM NY
11580-5437
US

IV. Provider business mailing address

30 S CENTRAL AVE STE 201
VALLEY STREAM NY
11580-5437
US

V. Phone/Fax

Practice location:
  • Phone: 516-791-8664
  • Fax:
Mailing address:
  • Phone: 516-791-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011114
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: