Provider Demographics
NPI:1023616307
Name:RIVERA, MANUEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
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 1:60 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-4009
Mailing Address - Country:US
Mailing Address - Phone:203-715-4290
Mailing Address - Fax:
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1541
Practice Address - Country:US
Practice Address - Phone:860-550-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5467363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant