Provider Demographics
NPI:1952723892
Name:RIVERA, OLIVIA LEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:LEE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:LEE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1468 FAIRWOOD CT SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9738
Mailing Address - Country:US
Mailing Address - Phone:616-204-7475
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE STE 6100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2561
Practice Address - Country:US
Practice Address - Phone:616-267-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006892363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant