Provider Demographics
NPI:1053611343
Name:RIVERA, STEPHANIE A (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:A
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MCPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:PO BOX 690609
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32869-0609
Mailing Address - Country:US
Mailing Address - Phone:407-846-7546
Mailing Address - Fax:321-206-5419
Practice Address - Street 1:7932 W SAND LAKE RD STE 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7299
Practice Address - Country:US
Practice Address - Phone:407-846-7546
Practice Address - Fax:321-206-5419
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT 9105625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006778500Medicaid
FL006778500Medicaid