Provider Demographics
NPI:1528644424
Name:RENICKER, MICAH DAVID (MD)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:DAVID
Last Name:RENICKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 W EVERGREEN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6952
Mailing Address - Country:US
Mailing Address - Phone:907-861-1450
Mailing Address - Fax:833-906-2375
Practice Address - Street 1:209 W EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6952
Practice Address - Country:US
Practice Address - Phone:907-861-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK228046207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine