Provider Demographics
NPI:1548226525
Name:RIVERA, RICHARD GIL (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:GIL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 TOWER RD NE STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9412
Mailing Address - Country:US
Mailing Address - Phone:770-422-1372
Mailing Address - Fax:770-999-2488
Practice Address - Street 1:3369 BUFORD HWY NE
Practice Address - Street 2:SUITE 810
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-3722
Practice Address - Country:US
Practice Address - Phone:404-321-4692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3833363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3833OtherLICENSE
GAP58444Medicare UPIN
GA97WCDLGMedicare PIN
GA3833OtherLICENSE
GA202I979839Medicare PIN