Provider Demographics
NPI:1982362752
Name:RIVERA, DOMINIQUE BREANN (PA-C)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:BREANN
Last Name:RIVERA
Suffix:
Gender:F
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 1:4301 ATHERTON WAY NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1260
Mailing Address - Country:US
Mailing Address - Phone:505-280-9586
Mailing Address - Fax:
Practice Address - Street 1:6801 JEFFERSON ST NE STE 350
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4361
Practice Address - Country:US
Practice Address - Phone:505-847-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMPA2023-0236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program