Provider Demographics
NPI:1528131786
Name:RIVEIRA, MARY ANN (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:RIVEIRA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E OCEAN BLVD
Mailing Address - Street 2:#2212
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-6934
Mailing Address - Country:US
Mailing Address - Phone:562-234-6866
Mailing Address - Fax:562-432-6053
Practice Address - Street 1:3510 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2010
Practice Address - Country:US
Practice Address - Phone:626-300-0229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA2154367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN4085640Medicaid
CANA2154Medicare ID - Type Unspecified
CARN4085640Medicaid