Provider Demographics
NPI:1457014821
Name:RIVERA SOTO, LUIS DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:DAVID
Last Name:RIVERA SOTO
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 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:305-666-6511
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-666-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115235363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant