Provider Demographics
NPI:1225479868
Name:RIVERA, LYDIA H (NP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:H
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N GRAND AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-1061
Mailing Address - Country:US
Mailing Address - Phone:520-761-2133
Mailing Address - Fax:520-281-1112
Practice Address - Street 1:1209 W TARGET RANGE RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2466
Practice Address - Country:US
Practice Address - Phone:520-287-4747
Practice Address - Fax:520-285-3136
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5061363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ836331Medicaid
AZPENDINGMedicare PIN