Healthcare Provider Details

I. General information

NPI: 1194243212
Provider Name (Legal Business Name): STEPHEN ANDREW RIVERA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 E 29TH AVE
SPOKANE WA
99223-4811
US

IV. Provider business mailing address

PO BOX 2928
PORTLAND OR
97208-2928
US

V. Phone/Fax

Practice location:
  • Phone: 888-227-3312
  • Fax: 509-227-7070
Mailing address:
  • Phone: 425-207-5155
  • Fax: 865-560-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54864
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61155898
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: