Provider Demographics
NPI:1003214297
Name:RIVERA, SHANNON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9449 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2814
Mailing Address - Country:US
Mailing Address - Phone:562-657-4530
Mailing Address - Fax:
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-962-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant