Provider Demographics
NPI:1295730166
Name:RIVERA, VICTOR MANUEL (CRNA)
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:MANUEL
Last Name:RIVERA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:VICTOR
Other - Middle Name:MANUEL
Other - Last Name:RIVERA-DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:11511 YATES ST
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2931
Mailing Address - Country:US
Mailing Address - Phone:301-649-6346
Mailing Address - Fax:
Practice Address - Street 1:11511 YATES ST
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-2931
Practice Address - Country:US
Practice Address - Phone:301-649-6346
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR055349163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0000XNursing Service ProvidersRegistered NursePain Management