Provider Demographics
NPI:1346707171
Name:RIVERA, EDSEL I
Entity Type:Individual
Prefix:
First Name:EDSEL
Middle Name:I
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 1:379 CALLE ANDRADES
Mailing Address - Street 2:
Mailing Address - City:CATANO
Mailing Address - State:PR
Mailing Address - Zip Code:00962-5034
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CENTURY BUSINESS PARK
Practice Address - Street 2:23 CARR 848
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985
Practice Address - Country:US
Practice Address - Phone:939-457-3065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR35690363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner