Provider Demographics
NPI:1467040204
Name:RIVERA, LISA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
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 1:312 N ALMA SCHOOL RD STE 11
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4354
Mailing Address - Country:US
Mailing Address - Phone:602-762-8142
Mailing Address - Fax:
Practice Address - Street 1:2350 BUHNE ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-3238
Practice Address - Country:US
Practice Address - Phone:707-443-4593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8720363A00000X, 363AM0700X
TX718429363AM0700X
CAPA65595363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ105817Medicaid
CAPA65595OtherCALIFORNIA LICENSE