Provider Demographics
NPI:1477895621
Name:RIVAS, GARY FRANK (RD, PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:FRANK
Last Name:RIVAS
Suffix:
Gender:M
Credentials:RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-1316
Mailing Address - Country:US
Mailing Address - Phone:626-444-0333
Mailing Address - Fax:626-582-7990
Practice Address - Street 1:3144 SANTA ANITA AVE
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-1316
Practice Address - Country:US
Practice Address - Phone:626-444-0333
Practice Address - Fax:626-582-7990
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61522363A00000X
CA1057294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered