Healthcare Provider Details

I. General information

NPI: 1689381824
Provider Name (Legal Business Name): MARVIN RIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2022
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 W RANDOL MILL RD STE 120
ARLINGTON TX
76012-2579
US

IV. Provider business mailing address

951 LAS PALMAS ENTRADA AVE APT 2126
HENDERSON NV
89012-5631
US

V. Phone/Fax

Practice location:
  • Phone: 817-801-1503
  • Fax: 817-801-1508
Mailing address:
  • Phone: 469-288-0058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberPA2761
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19534
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: