Provider Demographics
NPI:1417517996
Name:RIVAS, JUAN CARLOS (APRN)
Entity Type:Individual
Prefix:
First Name:JUAN CARLOS
Middle Name:
Last Name:RIVAS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 N MCLEAN BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-5900
Mailing Address - Country:US
Mailing Address - Phone:316-358-0025
Mailing Address - Fax:316-776-4554
Practice Address - Street 1:439 N MCLEAN BLVD STE 204
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-5900
Practice Address - Country:US
Practice Address - Phone:316-358-0025
Practice Address - Fax:316-776-4554
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112763363L00000X
KS80189363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner