Provider Demographics
NPI:1447868807
Name:RIVERA, JENNIFER MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:RIVERA
Suffix:
Gender:F
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 1:707 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2650
Mailing Address - Country:US
Mailing Address - Phone:845-333-3370
Mailing Address - Fax:845-333-3372
Practice Address - Street 1:707 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2650
Practice Address - Country:US
Practice Address - Phone:845-333-3370
Practice Address - Fax:845-333-3372
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant