Provider Demographics
NPI:1548453731
Name:RIVERA, ATALIE IRENE (PAC)
Entity type:Individual
Prefix:MRS
First Name:ATALIE
Middle Name:IRENE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-22
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA9104226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284523201Medicaid
TX854N58OtherBCBS
TX284523202Medicaid
TX75-2616977-042OtherTRICARE
TX75-2616977-042OtherTRICARE
TX284523202Medicaid