Provider Demographics
NPI:1922180413
Name:RILEY, JOHN O (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:O
Last Name:RILEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201849
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99520-1849
Mailing Address - Country:US
Mailing Address - Phone:907-792-6561
Mailing Address - Fax:907-792-6546
Practice Address - Street 1:1217 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-4003
Practice Address - Country:US
Practice Address - Phone:907-257-4603
Practice Address - Fax:907-792-6546
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKR14835Medicare UPIN