Provider Demographics
NPI:1902389166
Name:RIVERA, ANDREW DE LEON (PTA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DE LEON
Last Name:RIVERA
Suffix:
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 1:15418 EXCELLER BND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-4659
Mailing Address - Country:US
Mailing Address - Phone:830-212-0750
Mailing Address - Fax:
Practice Address - Street 1:506 S 7TH ST
Practice Address - Street 2:
Practice Address - City:CARRIZO SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78834-3815
Practice Address - Country:US
Practice Address - Phone:830-876-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2085367225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant