Provider Demographics
NPI:1740935931
Name:RIVES, JAMES BRENDAN (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:BRENDAN
Last Name:RIVES
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:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:1001 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5155
Practice Address - Country:US
Practice Address - Phone:417-875-3742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022005480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220106591Medicaid