Provider Demographics
NPI:1174290910
Name:RIVERA, MICHELLE RAE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RAE
Last Name:RIVERA
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 1:10901 E PUEBLO AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-3907
Mailing Address - Country:US
Mailing Address - Phone:480-467-8169
Mailing Address - Fax:
Practice Address - Street 1:10631 S 51ST ST STE 8
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5225
Practice Address - Country:US
Practice Address - Phone:480-418-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-28
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN158234363LF0000X
AZ265613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily