Provider Demographics
NPI:1376008250
Name:RILEY, JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RILEY
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 1:900 W UNIVERSITY DR STE A-2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1817
Mailing Address - Country:US
Mailing Address - Phone:248-266-0920
Mailing Address - Fax:
Practice Address - Street 1:900 W UNIVERSITY DR STE A-2
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1817
Practice Address - Country:US
Practice Address - Phone:248-266-0920
Practice Address - Fax:248-266-0898
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58656363A00000X
MI5601009005363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant