Provider Demographics
NPI:1275576738
Name:RIVERA, RICHARD ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 COUNTY ROAD 14
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-8719
Mailing Address - Country:US
Mailing Address - Phone:719-657-2510
Mailing Address - Fax:719-657-4106
Practice Address - Street 1:802 RIO GRANDE LN
Practice Address - Street 2:
Practice Address - City:CREEDE
Practice Address - State:CO
Practice Address - Zip Code:81130-9554
Practice Address - Country:US
Practice Address - Phone:719-658-0929
Practice Address - Fax:719-658-3001
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO636363A00000X
TXPA04083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07006364Medicaid
CO07006364Medicaid
COR18701Medicare UPIN