Provider Demographics
NPI:1083889737
Name:RIVAS, WYATT HARLAN (MD)
Entity Type:Individual
Prefix:
First Name:WYATT
Middle Name:HARLAN
Last Name:RIVAS
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:PO BOX 9787
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98909-0787
Mailing Address - Country:US
Mailing Address - Phone:509-575-8255
Mailing Address - Fax:509-225-3168
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3761
Practice Address - Country:US
Practice Address - Phone:509-575-8000
Practice Address - Fax:509-575-8745
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60215678207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program