Provider Demographics
NPI:1043456973
Name:RIVAS-TEJADA, DANIEL (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:RIVAS-TEJADA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6758 PASSONS BLVD
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-3666
Mailing Address - Country:US
Mailing Address - Phone:562-654-6899
Mailing Address - Fax:562-654-6895
Practice Address - Street 1:6758 PASSONS BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-3666
Practice Address - Country:US
Practice Address - Phone:562-654-6899
Practice Address - Fax:562-654-6895
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant