Provider Demographics
NPI:1679798342
Name:RIVERA, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:P ANTONIO
Other - Middle Name:
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:2151 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3121
Mailing Address - Country:US
Mailing Address - Phone:213-483-2222
Mailing Address - Fax:213-483-6161
Practice Address - Street 1:2151 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3121
Practice Address - Country:US
Practice Address - Phone:213-483-2222
Practice Address - Fax:213-483-6161
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13146363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical