Healthcare Provider Details

I. General information

NPI: 1083889737
Provider Name (Legal Business Name): WYATT HARLAN RIVAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 TIETON DR
YAKIMA WA
98902-3761
US

IV. Provider business mailing address

PO BOX 9787
YAKIMA WA
98909-0787
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-8000
  • Fax: 509-575-8745
Mailing address:
  • Phone: 509-575-8255
  • Fax: 509-225-3168

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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60215678
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: