Provider Demographics
NPI:1134963390
Name:RIVAS, EDGARDO MARIO CLAUDIO (SA-C)
Entity type:Individual
Prefix:
First Name:EDGARDO
Middle Name:MARIO CLAUDIO
Last Name:RIVAS
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:3001 NE 185TH ST APT 409
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3345
Mailing Address - Country:US
Mailing Address - Phone:786-593-6238
Mailing Address - Fax:
Practice Address - Street 1:3001 NE 185TH ST APT 409
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-3345
Practice Address - Country:US
Practice Address - Phone:786-593-6238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-328246ZC0007X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant