Provider Demographics
NPI:1316052111
Name:RIVERA, GLEN (PA-C)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
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 1:108 HOUSTON ST STE E
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-2455
Mailing Address - Country:US
Mailing Address - Phone:540-463-2227
Mailing Address - Fax:
Practice Address - Street 1:108 HOUSTON ST STE E
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-2455
Practice Address - Country:US
Practice Address - Phone:540-463-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006682363AM0700X
NC102256363AM0700X
VA0110002571363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN
S54857Medicare UPIN
157002ZARVMedicare PIN