Provider Demographics
NPI:1083892129
Name:RIVERA, WANDA (PA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
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 1:128 ASHFORD AVE
Mailing Address - Street 2:
Mailing Address - City:DOBBS FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:10522-1924
Mailing Address - Country:US
Mailing Address - Phone:914-693-0700
Mailing Address - Fax:914-693-4723
Practice Address - Street 1:128 ASHFORD AVE
Practice Address - Street 2:
Practice Address - City:DOBBS FERRY
Practice Address - State:NY
Practice Address - Zip Code:10522-1924
Practice Address - Country:US
Practice Address - Phone:914-693-0700
Practice Address - Fax:914-693-4723
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant