MEDICARE: MR. MARTIN E RIVERA CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	073074	MO
2	367500000X	Certified Registered Nurse Anesthetist	1139215	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184694416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN E RIVERA CRNA

Provider Business Mailing Address
First Line	:	PO BOX 220
Second Line	:
City	:	ROLLA
State	:	MO
Zip	:	65402-0220
Country	:	US
Telephone Number	:	573-458-8899
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 S JACKSON
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766
Country	:	US
Telephone Number	:	903-541-4630
Fax Number	:	903-586-5710

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	03/20/2025

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Directions to “ MR. MARTIN E RIVERA CRNA” Practice Location

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