Provider Demographics
NPI:1487942256
Name:KONOVAL, RIVA (PA)
Entity type:Individual
Prefix:
First Name:RIVA
Middle Name:
Last Name:KONOVAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N STATE ROAD 7
Mailing Address - Street 2:STE 211
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5625
Mailing Address - Country:US
Mailing Address - Phone:954-766-4233
Mailing Address - Fax:954-306-2056
Practice Address - Street 1:3500 N STATE ROAD 7
Practice Address - Street 2:STE 211
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5625
Practice Address - Country:US
Practice Address - Phone:954-766-4233
Practice Address - Fax:954-306-2056
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-14
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 2685OtherMEDICAL LICENSE