Provider Demographics
NPI:1124099049
Name:RIVAS, BENITO JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENITO
Middle Name:
Last Name:RIVAS
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12683 AVENUE 416
Mailing Address - Street 2:
Mailing Address - City:OROSI
Mailing Address - State:CA
Mailing Address - Zip Code:93647-2017
Mailing Address - Country:US
Mailing Address - Phone:559-528-4717
Mailing Address - Fax:559-528-0302
Practice Address - Street 1:12686 AVENUE 416
Practice Address - Street 2:
Practice Address - City:OROSI
Practice Address - State:CA
Practice Address - Zip Code:93647-2054
Practice Address - Country:US
Practice Address - Phone:559-528-4717
Practice Address - Fax:559-528-0302
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15862OtherPHYSICIAN ASSISTANT BOARD
CAP39748Medicare UPIN