Provider Demographics
NPI:1407630908
Name:MERCADO-RIVERA, JEANCARLO JAVIER
Entity type:Individual
Prefix:
First Name:JEANCARLO
Middle Name:JAVIER
Last Name:MERCADO-RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4050
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00614
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #2, KM. 80.4, BERRIO SAN DANIEL,
Practice Address - Street 2:SECTOR LAS CANELAS
Practice Address - City:ARECIBO
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00614
Practice Address - Country:UM
Practice Address - Phone:787-878-5475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL11032407367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program