Provider Demographics
NPI:1457640765
Name:RILEY, RACHEL VIRGINIA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:VIRGINIA
Last Name:RILEY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:VIRGINIA
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:PO BOX 400308
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92340-0308
Mailing Address - Country:US
Mailing Address - Phone:909-240-7939
Mailing Address - Fax:
Practice Address - Street 1:15248 ELEVENTH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3704
Practice Address - Country:US
Practice Address - Phone:760-245-8691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-07
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1096404364SF0001X
CAPA21546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health