1699836791 NPI number — YURI OLAF RIVERA PA-C

Table of content: YURI OLAF RIVERA PA-C (NPI 1699836791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699836791 NPI number — YURI OLAF RIVERA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIVERA
Provider First Name:
YURI
Provider Middle Name:
OLAF
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699836791
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-579-5463
Provider Business Mailing Address Fax Number:
601-579-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 WEEMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PURVIS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39475-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-794-2224
Provider Business Practice Location Address Fax Number:
601-794-6392
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA00120 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9116618 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 09075224 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5300264 . This is a "CIGNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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