Provider Demographics
NPI:1912594490
Name:RIVERA, SYDNEY LEE (PA)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:LEE
Last Name:RIVERA
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12016 LEMMOND FARM DR STE 100
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-8353
Practice Address - Country:US
Practice Address - Phone:704-863-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant