Healthcare Provider Details

I. General information

NPI: 1124782263
Provider Name (Legal Business Name): ULDA ELIZABETH RIVERA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 E BASELINE RD
PHOENIX AZ
85042-6948
US

IV. Provider business mailing address

4700 MILLENIA BLVD STE 650
ORLANDO FL
32839-6013
US

V. Phone/Fax

Practice location:
  • Phone: 602-834-9071
  • Fax: 877-541-4239
Mailing address:
  • Phone: 407-533-6836
  • Fax: 407-232-9316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8636
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: