Provider Demographics
NPI:1598002248
Name:RIVERA, LOURDES MARIA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LOURDES
Middle Name:MARIA
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LOURDES
Other - Middle Name:MARIA
Other - Last Name:PERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 743144
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 N KENDALL DR
Practice Address - Street 2:MIAMI CANCER INSTITUTE
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-2118
Practice Address - Country:US
Practice Address - Phone:786-596-2000
Practice Address - Fax:305-279-7778
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008798400Medicaid
FLHG462YMedicare PIN