Healthcare Provider Details

I. General information

NPI: 1497690218
Provider Name (Legal Business Name): ORLANDO XAVIER RIVERA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 MARCUS GARVEY BLVD
BROOKLYN NY
11221-1114
US

IV. Provider business mailing address

556 ONDERDONK AVE
RIDGEWOOD NY
11385-2576
US

V. Phone/Fax

Practice location:
  • Phone: 718-453-9377
  • Fax: 718-802-1113
Mailing address:
  • Phone: 347-235-7232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number035506-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: