Provider Demographics
NPI:1689381824
Name:RIVERA, MARVIN
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
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 1:951 LAS PALMAS ENTRADA AVE APT 2126
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-5631
Mailing Address - Country:US
Mailing Address - Phone:469-288-0058
Mailing Address - Fax:
Practice Address - Street 1:2850 W HORIZON RIDGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4395
Practice Address - Country:US
Practice Address - Phone:702-313-8446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2761208600000X
390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program