Provider Demographics
NPI:1376876805
Name:RIVAS, JOSE LUIS (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:RIVAS
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 1:24165 W IH 10
Mailing Address - Street 2:STE 123
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1160
Mailing Address - Country:US
Mailing Address - Phone:210-545-7171
Mailing Address - Fax:
Practice Address - Street 1:1139 E SONTERRA BLVD
Practice Address - Street 2:500
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4347
Practice Address - Country:US
Practice Address - Phone:210-545-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
8BH978OtherBCBS
8BH978OtherBCBS
TXB113119Medicare PIN