Provider Demographics
NPI:1104472711
Name:RIVAS, GILMA LIZAIDA
Entity type:Individual
Prefix:
First Name:GILMA
Middle Name:LIZAIDA
Last Name:RIVAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12520 FAIRWOOD PKWY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6343
Mailing Address - Country:US
Mailing Address - Phone:301-262-2300
Mailing Address - Fax:844-888-1044
Practice Address - Street 1:12520 FAIRWOOD PKWY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6343
Practice Address - Country:US
Practice Address - Phone:301-262-2300
Practice Address - Fax:844-888-1044
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2025-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR194206OtherSTATE LICENSE