Healthcare Provider Details

I. General information

NPI: 1467040204
Provider Name (Legal Business Name): LISA MARIE RIVERA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 BUHNE ST
EUREKA CA
95501-3238
US

IV. Provider business mailing address

312 N ALMA SCHOOL RD STE 11
CHANDLER AZ
85224-4354
US

V. Phone/Fax

Practice location:
  • Phone: 707-443-4593
  • Fax:
Mailing address:
  • Phone: 602-762-8142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8720
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8720
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number718429
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65595
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: