Provider Demographics
NPI:1366957425
Name:PATRICIO, ROGER RIVERA JR
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:RIVERA
Last Name:PATRICIO
Suffix:JR
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 1:5479 ATRIUM WOODS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1218
Mailing Address - Country:US
Mailing Address - Phone:702-767-6374
Mailing Address - Fax:
Practice Address - Street 1:6276 S RAINBOW BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3243
Practice Address - Country:US
Practice Address - Phone:702-396-4165
Practice Address - Fax:702-252-4405
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002758207RI0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease