Provider Demographics
NPI:1457834160
Name:RENIVA, MICHAEL ANGELO (DNP APN/CRNA)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANGELO
Last Name:RENIVA
Suffix:
Gender:M
Credentials:DNP APN/CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 DOUGLAS TER
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-6523
Mailing Address - Country:US
Mailing Address - Phone:908-884-9318
Mailing Address - Fax:
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-884-9318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00928900367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered