Healthcare Provider Details

I. General information

NPI: 1619768918
Provider Name (Legal Business Name): ELISA RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 WOODBROOKE DR
SALISBURY MD
21804-8501
US

IV. Provider business mailing address

1630 WOODBROOKE DR
SALISBURY MD
21804-8501
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-6330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: