Provider Demographics
NPI:1215912704
Name:RIVERA, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 HARRISON ST
Mailing Address - Street 2:SOUTHERN TIER PULMONARY
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2120
Mailing Address - Country:US
Mailing Address - Phone:607-729-8845
Mailing Address - Fax:607-729-5574
Practice Address - Street 1:52 HARRISON ST
Practice Address - Street 2:SOUTHERN TIER PULMONARY
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2120
Practice Address - Country:US
Practice Address - Phone:607-729-8845
Practice Address - Fax:607-729-5574
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB6693Medicare PIN
B35507Medicare UPIN