Provider Demographics
NPI:1134699838
Name:SUAREZ RIVERA, JAVIER JESUS
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:JESUS
Last Name:SUAREZ RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 CASWELL SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-8325
Mailing Address - Country:US
Mailing Address - Phone:502-298-9121
Mailing Address - Fax:
Practice Address - Street 1:11415 CASWELL SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-8325
Practice Address - Country:US
Practice Address - Phone:502-298-9121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2024-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
KY4018518363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty