Provider Demographics
NPI:1205374162
Name:RIVERA, RUDY
Entity Type:Individual
Prefix:
First Name:RUDY
Middle Name:
Last Name: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 1:18818 MEISNER DR
Mailing Address - Street 2:STE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3569
Mailing Address - Country:US
Mailing Address - Phone:210-481-6800
Mailing Address - Fax:210-481-1444
Practice Address - Street 1:150 E SONTERRA BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4098
Practice Address - Country:US
Practice Address - Phone:210-481-6800
Practice Address - Fax:210-481-1444
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant