Provider Demographics
NPI:1861509390
Name:RIVERA, MARY ANNE M (MS PA)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:M
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MS PA
Other - Prefix:
Other - First Name:MARY ANNE
Other - Middle Name:
Other - Last Name:GAMAO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PA
Mailing Address - Street 1:40 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-2431
Mailing Address - Country:US
Mailing Address - Phone:973-635-0800
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NJ
Practice Address - Zip Code:07928-2431
Practice Address - Country:US
Practice Address - Phone:973-635-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00129300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant