Provider Demographics
NPI:1255806535
Name:RIVERA LANDEROS, WILLIE (PA)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:RIVERA LANDEROS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:WILLIE
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5475 CANYON CREST DR APT 92
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6440
Mailing Address - Country:US
Mailing Address - Phone:951-565-7577
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56066363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant