Provider Demographics
NPI:1891922241
Name:PAGAN RIVERA, MIRIAM YAZMIN (LND)
Entity Type:Individual
Prefix:MISS
First Name:MIRIAM
Middle Name:YAZMIN
Last Name:PAGAN RIVERA
Suffix:
Gender:F
Credentials:LND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB.EXT. JARDINES DE COAMO CALLE -10 G-6
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:P.R.
Mailing Address - Zip Code:00769
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PONCE HEALTH SCIENCES UNIVERSITY
Practice Address - Street 2:INDUSTRIAL REPARADA CALLE 10 G 6
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716
Practice Address - Country:US
Practice Address - Phone:787-204-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-12
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1503133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4119508Medicaid