Provider Demographics
NPI:1477717528
Name:RIVERA, LEESHUN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MISS
First Name:LEESHUN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:MMC DEPARTMENT OF OBSTETRICS & GYNECOLOGY AND WOMEN'S H
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-405-8020
Mailing Address - Fax:718-405-8110
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:MMC DEPARTMENT OF OBSTETRICS & GYNECOLOGY AND WOMEN'S H
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-405-8020
Practice Address - Fax:718-405-8110
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY008535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant