Provider Demographics
NPI:1346884806
Name:RIVERA, JUSTIN GUY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:GUY
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8107 SILVER HAMPTON
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-2805
Mailing Address - Country:US
Mailing Address - Phone:951-990-0268
Mailing Address - Fax:
Practice Address - Street 1:6841 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7202
Practice Address - Country:US
Practice Address - Phone:210-901-6743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57420207Q00000X
TXPA14175261QU0200X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care