Provider Demographics
NPI:1336573633
Name:KIVETTE, CAELAN RIVER SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:CAELAN RIVER
Middle Name:SCOTT
Last Name:KIVETTE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:SCOTT
Other - Last Name:KIVETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3140 ROWENA AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-4447
Mailing Address - Country:US
Mailing Address - Phone:860-918-0020
Mailing Address - Fax:
Practice Address - Street 1:3140 ROWENA AVE
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-4447
Practice Address - Country:US
Practice Address - Phone:860-918-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031107-01363A00000X
NC0010-04332363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant