Provider Demographics
NPI:1649038902
Name:RIVAS, MIGUEL A (PA-C)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:A
Last Name:RIVAS
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 1:519 S ROSELLE RD
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-2925
Mailing Address - Country:US
Mailing Address - Phone:847-618-5450
Mailing Address - Fax:
Practice Address - Street 1:519 S ROSELLE RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-2925
Practice Address - Country:US
Practice Address - Phone:847-618-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.010275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant