Provider Demographics
NPI:1942877303
Name:RIVERA CRUZ, PABLO ANGEL (SA-C)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ANGEL
Last Name:RIVERA CRUZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2543 S EL DORADO ST SPC 71
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-3280
Mailing Address - Country:US
Mailing Address - Phone:209-688-9843
Mailing Address - Fax:
Practice Address - Street 1:2543 S EL DORADO ST SPC 71
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-3280
Practice Address - Country:US
Practice Address - Phone:209-688-9843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19-309246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant