Provider Demographics
NPI:1134280118
Name:RIVAS, STACI M (CRNA)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:M
Last Name:RIVAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:M
Other - Last Name:RIVAS PARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:4070 DELP MAIL STOP 4017
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-6612
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:2026 DELP PAVILION MAIL STOP 2020
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160
Practice Address - Country:US
Practice Address - Phone:913-588-6619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS54684367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04747Medicare UPIN
P00300778Medicare ID - Type UnspecifiedRAILROAD MEDICARE
617B930AMedicare ID - Type Unspecified