Provider Demographics
NPI:1134114739
Name:RIVERS, PEGGY J (ANP)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:J
Last Name:RIVERS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17175 SW TV HWY STE B2
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4584
Mailing Address - Country:US
Mailing Address - Phone:503-941-3017
Mailing Address - Fax:
Practice Address - Street 1:17175 SW TV HWY STE B2
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97006-4584
Practice Address - Country:US
Practice Address - Phone:503-941-3017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250074NP ANP-PP363LA2200X
WAAP30006298363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
825622005OtherBLUE CROSS/BLUE SHIELD/TRIWEST
OR0009OtherWORKMAN'S COMPENSATION CERTIFIED PROVIDER
OR136378Medicare PIN
ORQ75774Medicare UPIN