Provider Demographics
NPI:1275388852
Name:PATAWARAN, JUSTIN AARON RIVERA
Entity Type:Individual
Prefix:
First Name:JUSTIN AARON
Middle Name:RIVERA
Last Name:PATAWARAN
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 1:2874 POINTE DR
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:TX
Mailing Address - Zip Code:77539-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3006
Practice Address - Country:US
Practice Address - Phone:580-924-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36112732390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program