Provider Demographics
NPI:1376578583
Name:RIVES, ANTHONY N (PA-C)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:N
Last Name:RIVES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1657 N EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1276
Mailing Address - Country:US
Mailing Address - Phone:770-228-2641
Mailing Address - Fax:770-467-9764
Practice Address - Street 1:1657 N EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-1276
Practice Address - Country:US
Practice Address - Phone:770-228-2641
Practice Address - Fax:770-467-9764
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103779363AS0400X
GA004177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP96174Medicare UPIN