Healthcare Provider Details

I. General information

NPI: 1861200990
Provider Name (Legal Business Name): MATTHEW AARON RIVADENEIRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 LYNWOOD DR
VALLEY STREAM NY
11580-3327
US

IV. Provider business mailing address

28 LYNWOOD DR
VALLEY STREAM NY
11580-3327
US

V. Phone/Fax

Practice location:
  • Phone: 516-660-4148
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036404
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: