Provider Demographics
NPI:1851480321
Name:RIVERA, ELISA (PAC)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20144 MORTON RD # 202
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-3726
Mailing Address - Country:US
Mailing Address - Phone:443-813-1075
Mailing Address - Fax:281-781-2560
Practice Address - Street 1:20144 MORTON RD # 202
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-3726
Practice Address - Country:US
Practice Address - Phone:443-813-1075
Practice Address - Fax:281-781-2560
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187974401Medicaid
TX8L24337Medicare PIN
R59692Medicare UPIN
TX8B6144Medicare PIN