Provider Demographics
NPI:1225165319
Name:RIVERA-LAKE, DOMINGO A (PA)
Entity Type:Individual
Prefix:
First Name:DOMINGO
Middle Name:A
Last Name:RIVERA-LAKE
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 1:6 DUNE CT
Mailing Address - Street 2:APT 1
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-1662
Mailing Address - Country:US
Mailing Address - Phone:866-662-9729
Mailing Address - Fax:718-798-7983
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:MMC - DEPT OF RADIOLOGY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:866-662-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant