Provider Demographics
NPI:1184053423
Name:RIVERA, REBECCA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BIBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-487-5751
Practice Address - Street 1:7725 HIGHWAY 62 STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111
Practice Address - Country:US
Practice Address - Phone:812-280-0413
Practice Address - Fax:812-280-0465
Is Sole Proprietor?:No
Enumeration Date:2013-11-07
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001839A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007796Medicaid
ININ1189154OtherIN MEDICARE
TXPA08679OtherTEXAS MEDICAL BOARD PA LICENSE NUMBER