Provider Demographics
NPI:1497296594
Name:RIVA, SPENCER PATRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:PATRICK
Last Name:RIVA
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 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:
Practice Address - Street 1:1246 MADISON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1761
Practice Address - Country:US
Practice Address - Phone:616-685-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant