Healthcare Provider Details

I. General information

NPI: 1790648277
Provider Name (Legal Business Name): MANUEL CARDENAS RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2025
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 COLUMBIA 100 PKWY STE 430
COLUMBIA MD
21045-2175
US

IV. Provider business mailing address

8820 COLUMBIA 100 PKWY STE 430
COLUMBIA MD
21045-2175
US

V. Phone/Fax

Practice location:
  • Phone: 410-967-2097
  • Fax:
Mailing address:
  • Phone: 410-967-2097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number28260160C
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: