Provider Demographics
NPI:1699836791
Name:RIVERA, YURI OLAF (PA-C)
Entity Type:Individual
Prefix:
First Name:YURI
Middle Name:OLAF
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:101 WEEMS ST
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-4062
Practice Address - Country:US
Practice Address - Phone:601-794-2224
Practice Address - Fax:601-794-6392
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00120363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS9116618OtherAETNA
MS09075224Medicaid
MS5300264OtherCIGNA
MSP00896969OtherRAILROAD MEDICARE
MS9116618OtherAETNA