MEDICARE: MR. VICTOR MANUEL RIVERA CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WP0000X	Pain Management Registered Nurse	R055349	MD

General Provider Information

NPI Number	:	1295730166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR MANUEL RIVERA CRNA

Provider Business Mailing Address
First Line	:	11511 YATES ST
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-2931
Country	:	US
Telephone Number	:	301-649-6346
Fax Number	:

Provider Business Practice Location Address
First Line	:	11511 YATES ST
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-2931
Country	:	US
Telephone Number	:	301-649-6346
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	07/08/2007

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