Provider Demographics
NPI:1154335792
Name:RIVERA, SANTOS MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:SANTOS
Middle Name:MICHAEL
Last Name:RIVERA
Suffix:
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 1:3463 MAGIC DR STE T21
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3621
Mailing Address - Country:US
Mailing Address - Phone:210-614-8101
Mailing Address - Fax:210-614-8102
Practice Address - Street 1:3463 MAGIC DR STE T21
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-8101
Practice Address - Fax:210-614-8102
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01255363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX88N947OtherBCBS OF TEXAS
TX88N947OtherBCBS OF TEXAS
TX8722M1Medicare ID - Type Unspecified