Provider Demographics
NPI:1508044595
Name:RICKETTS-LORIAUX, REVA S (DO)
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:S
Last Name:RICKETTS-LORIAUX
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3158 SW FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1467
Mailing Address - Country:US
Mailing Address - Phone:503-530-6648
Mailing Address - Fax:
Practice Address - Street 1:3158 SW FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1467
Practice Address - Country:US
Practice Address - Phone:503-530-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002314207ZP0102X
ORDO26757207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology