MEDICARE: MS. OLIVIA LEE RIVERA PA-C

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	363A00000X	Physician Assistant	5601006892	MI

General Provider Information

NPI Number	:	1952723892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. OLIVIA LEE RIVERA PA-C

Provider Business Mailing Address
First Line	:	1468 FAIRWOOD CT SE
Second Line	:
City	:	CALEDONIA
State	:	MI
Zip	:	49316-9738
Country	:	US
Telephone Number	:	616-204-7475
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 MICHIGAN ST NE STE 6100
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2561
Country	:	US
Telephone Number	:	616-267-7900
Fax Number	:

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

Provider Enumeration Date	:	01/13/2014
Last Update Date	:	06/29/2020

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