Provider Demographics
NPI:1063477453
Name:RIVERA, MARIA MAGDALENA (PA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:MAGDALENA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARKLAND DR
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038
Mailing Address - Country:US
Mailing Address - Phone:603-432-1500
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLAND DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038
Practice Address - Country:US
Practice Address - Phone:603-432-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102768363A00000X
MA1408363A00000X
NH0635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL214759OtherAMERIGROUP
NH30336586Medicaid
NHP00774148OtherRAILROAD MEDICARE
FL292232100Medicaid
NHP00774148OtherRAILROAD MEDICARE
FLU2918YMedicare ID - Type Unspecified
FL214759OtherAMERIGROUP
NHAP158502Medicare PIN