Provider Demographics
NPI:1861474033
Name:RIVERA, EDWIN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4647 ZION AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2507
Mailing Address - Country:US
Mailing Address - Phone:619-528-2595
Mailing Address - Fax:
Practice Address - Street 1:4647 ZION AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2507
Practice Address - Country:US
Practice Address - Phone:619-528-2595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14420363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical