Provider Demographics
NPI:1730697715
Name:RIVERA, ROGER (DNP)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:RIVERA
Suffix:
Gender:
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 W MONUMENT AVE STE 29
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5192
Mailing Address - Country:US
Mailing Address - Phone:407-753-1500
Mailing Address - Fax:321-710-1767
Practice Address - Street 1:22 W MONUMENT AVE STE 29
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5192
Practice Address - Country:US
Practice Address - Phone:407-753-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-12
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN10457546363LF0000X
FLARNP9484520363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty