Provider Demographics
NPI:1750016804
Name:MALDONADO RIVERA, MARIO JR (PA)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:MALDONADO RIVERA
Suffix:JR
Gender:M
Credentials:PA
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 54
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00960-0054
Mailing Address - Country:US
Mailing Address - Phone:787-363-5319
Mailing Address - Fax:
Practice Address - Street 1:CALLE 2
Practice Address - Street 2:B44 URBANIZACION ALTURAS DE FLAMBOYAN
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-363-5319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1330363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant