Healthcare Provider Details

I. General information

NPI: 1982362752
Provider Name (Legal Business Name): DOMINIQUE BREANN RIVERA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7704 2ND ST NW
ALBUQUERQUE NM
87107-6755
US

IV. Provider business mailing address

4301 ATHERTON WAY NW
ALBUQUERQUE NM
87120-1260
US

V. Phone/Fax

Practice location:
  • Phone: 505-890-1458
  • Fax:
Mailing address:
  • Phone: 505-280-9586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2023-0236
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: