=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689381824
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARVIN RIVERA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2022
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 W RANDOL MILL RD STE 120
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76012-2579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-801-1503
-----------------------------------------------------
Fax | 817-801-1508
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 951 LAS PALMAS ENTRADA AVE APT 2126
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89012-5631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-288-0058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | PA2761
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA19534
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------