Provider Demographics
NPI:1508158767
Name:RIVERA, KATIERA TEKAKWITHA (DO)
Entity Type:Individual
Prefix:
First Name:KATIERA
Middle Name:TEKAKWITHA
Last Name:RIVERA
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:PO BOX 3031
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-3031
Mailing Address - Country:US
Mailing Address - Phone:406-752-3239
Mailing Address - Fax:406-752-3252
Practice Address - Street 1:210 NW BARSTOW ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3771
Practice Address - Country:US
Practice Address - Phone:262-548-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MT34958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program