Provider Demographics
NPI:1154076933
Name:LARIVIERE, WILBEN ANDY (PA)
Entity Type:Individual
Prefix:
First Name:WILBEN
Middle Name:ANDY
Last Name:LARIVIERE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 S VINEYARD STE 119
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6890
Mailing Address - Country:US
Mailing Address - Phone:480-300-4646
Mailing Address - Fax:
Practice Address - Street 1:2045 S VINEYARD STE 119
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6890
Practice Address - Country:US
Practice Address - Phone:480-300-4646
Practice Address - Fax:480-300-4646
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1212-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical