Provider Demographics
NPI:1740557313
Name:RIVERA, LUIS FERNANDO JR (PTA)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:FERNANDO
Last Name:RIVERA
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21415 43RD AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-6841
Mailing Address - Country:US
Mailing Address - Phone:253-359-4195
Mailing Address - Fax:
Practice Address - Street 1:21415 43RD AVENUE CT E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-6841
Practice Address - Country:US
Practice Address - Phone:253-359-4195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-25
Last Update Date:2011-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160103900171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor