Provider Demographics
NPI:1629534649
Name:RIVERA, DAVID A
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 CRUGER AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-2363
Mailing Address - Country:US
Mailing Address - Phone:347-761-5239
Mailing Address - Fax:
Practice Address - Street 1:2105 CRUGER AVE APT 3G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-2363
Practice Address - Country:US
Practice Address - Phone:347-761-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant