Provider Demographics
NPI:1427043132
Name:RIVERA, MICHAEL CUE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CUE
Last Name:RIVERA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 MULLIKEN ST
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-1233
Mailing Address - Country:US
Mailing Address - Phone:618-594-3613
Mailing Address - Fax:888-859-4347
Practice Address - Street 1:1110 MULLIKEN ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-1233
Practice Address - Country:US
Practice Address - Phone:618-594-3613
Practice Address - Fax:888-859-4347
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002421363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S96457Medicare UPIN
IL566130Medicare ID - Type Unspecified