Provider Demographics
NPI:1184694416
Name:RIVERA, MARTIN E (CRNA)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:E
Last Name:RIVERA
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0220
Mailing Address - Country:US
Mailing Address - Phone:573-458-8899
Mailing Address - Fax:
Practice Address - Street 1:2626 S JACKSON
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766
Practice Address - Country:US
Practice Address - Phone:903-541-4630
Practice Address - Fax:903-586-5710
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO073074367500000X
TX1139215367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO917426801Medicaid