Provider Demographics
NPI:1356523450
Name:RIVERA, GENO ROMAN (PTA)
Entity type:Individual
Prefix:
First Name:GENO
Middle Name:ROMAN
Last Name:RIVERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 E ROMA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-4250
Mailing Address - Country:US
Mailing Address - Phone:602-571-4407
Mailing Address - Fax:
Practice Address - Street 1:16605 E PALISADES BLVD STE 144
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3717
Practice Address - Country:US
Practice Address - Phone:602-571-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7926A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant