Provider Demographics
NPI:1699043307
Name:RIVINUS, MARK C (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:RIVINUS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WEST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOPKINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748
Mailing Address - Country:US
Mailing Address - Phone:508-530-3140
Mailing Address - Fax:
Practice Address - Street 1:50 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HOPKINTON
Practice Address - State:MA
Practice Address - Zip Code:01748-1672
Practice Address - Country:US
Practice Address - Phone:508-530-3140
Practice Address - Fax:603-893-8886
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN148420367500000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered