Provider Demographics
NPI:1265738942
Name:RIVERA, CARLOS (FNP-BC)
Entity type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W CAMELBACK RD STE A262
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2529
Mailing Address - Country:US
Mailing Address - Phone:623-377-2747
Mailing Address - Fax:
Practice Address - Street 1:24 W CAMELBACK RD STE A262
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2529
Practice Address - Country:US
Practice Address - Phone:623-377-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-28
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN157120163WE0003X
AZAP8840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ168809Medicaid