Provider Demographics
NPI:1336726447
Name:DE LA RIVA, CHARLES C JR (NP-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:DE LA RIVA
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E EARLL DR STE 360
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2677
Mailing Address - Country:US
Mailing Address - Phone:480-788-5621
Mailing Address - Fax:480-779-1277
Practice Address - Street 1:202 E EARLL DR STE 360
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2677
Practice Address - Country:US
Practice Address - Phone:480-788-5621
Practice Address - Fax:480-779-1277
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ192810163W00000X
AZ261707163W00000X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ261707OtherNURSE PRACTITIONER
AZ192810OtherREGISTERED NURSE