Provider Demographics
NPI:1316184427
Name:RIVERA, EDWIN FERNANDO SR (RPA)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:FERNANDO
Last Name:RIVERA
Suffix:SR
Gender:M
Credentials:RPA
Other - Prefix:
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Mailing Address - Street 1:560 1ST AVE
Mailing Address - Street 2:TISCH ROOM 1798
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-5430
Mailing Address - Fax:
Practice Address - Street 1:560 1ST AVE
Practice Address - Street 2:TISCH ROOM 1798
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY000778-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMR1822229OtherDEA NUMBER